
Glass 

Book_- 



COPYRIGHT DEPOSIT 



^ 



A SYSTEM 






M I D AYI F E R Y, 



IXCLUDIXG THE 



DISEASES OF PREGNANCY AND THE PUERPERAL STATE, 



/ BY 

WILLIAM LEISHMAlSr, M.D., 

REGICS PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF GLASGOW ; PHYSICIAN FOR DISEASI 

OF WOMEN, AND CONSULTING PHYSICIAN TO THE OBSTETRICAL DEPARTMENT IN THE 

GLASGOW WESTERN INFIRMARY ; FELLOW AND LATE VICE-PRESIDENT OF THE 

OBSTETRICAL SOCIETY OF LONDON ; CORRESPONDING MEMBER OF THE 

OBSTETRICAL SOCIETY OF EDINBURGH, AND OF THE 

OBSTETRICAL AND GYNECOLOGICAL SOCIETY 

OF BERLIN : ETC. ETC. ETC. 



<^S 



THIRD AMERICAN EDITION, REVISED BY THE AUTHOR. 



TVITH ADDITIONS BY 



JOHN S. PARRY, M.D. 



WITH TWO HUNDRED AND FIVE ILLUSTRATIONS. 




PHILADELPHIA: 

HEE^ET 0. LEA 

1879. 



,V-53 



Entered according to Act of Congress, in the year 1879, by 
HENKY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER. 



PREFACE TO THE THIRD AMERICAN EDITION. 



The publication of a Third American Edition of his work affords the 
Author an opportunity, of which he gladly avails himself, of expressing 
the great gratification which he has experienced in the generous appre- 
ciation of his labors by his colleagues in America. Of the many criti- 
cisms which have appeared, none have been more valuable or useful to 
him than those of the American Medical Press. 

The methods of teaching on the two sides of the Atlantic being some- 
what different, it has been found necessary to introduce some modifi- 
cations in order to make this and the previous edition quite intelligible. 
This has been ably done by Dr. John S. Parry; and, without commit- 
ting himself to all that has been added, the Author has much pleasure 
in acknowledging the courtesy and ability with which this task has been 
performed. 

In the preparation of the present Edition, such alterations have been 
made as the progress of Obstetrical Science seems to require. The 
large circulation which the work has attained has, indeed, imposed 
this duty upon the Author as one to be conscientiously and carefully 
discharged ; and in its performance he has been under many obliga- 
tions to Dr. James Finlayson, which he has here much pleasure in 
acknowledging. 

W. L. 

Glasgow, September, 1879. 



AMERICAN PUBLISHER'S NOTE. 



The lamented death of Dr. Parry, the former editor of this work, 
has deprived the present edition of the benefit of his further labors. 
His previous additions, however, were too valuable, and indeed too 
necessary to the American student, to be lost ; and such of them as 
have not been rendered superfluous by modifications of the text, have 
been inserted in their appropriate places. 

Philadelphia, October, 1879. 



CONTENTS. 



CHAPTER I. 

INTRODUCTORY. 



History of Midwifery. — Hippocratic Era. — Arabian School. — Ambroise Pare. — Mauri- 
ceau. — English Midwifery. — Objections to the Practice of Midwifery considered. — 
Comparative Anatomy of the Pelvis . — The Pelvis a Tube through which the Product 
of Conception Passes. — Parturition in the Primates : in the various Races. — The 
Erect Posture the Main Cause of Comparative Difficulty in Human Species. — The 
Human Pelvis a Curved Canal. — Separation of Pelvic Articulations during Labor. 
— Midwifery Defined, .......... 17-33 

CHAPTER II. 

THE PELVIS. 

Os Innominatum : Sacrum : Coccyx. — The Pelvis as a Whole : " True" and " False." 
— Difference between Male and Female Pelvis : at Brim ; in Cavity ; and at Out- 
let. — Pelvic Articulations : (a) Pelvi-Lumbar ; (h) Sacro-Coccygeal ; (c) Sacro- 
Hiac ; (d) Symphysis Pubis ; (e) Obturator Ligaments ; (/) Sacro-Sciatic Liga- 
ments. — Inclination of Pelvis. — Axis of the True Pelvis. — Brim or Inlet. — Cavity. — 
Outlet. — Pelvic Diameters. — Pelvic Angles. — Development of Pelvis. — Certain Soft 
Parts connected with Pelvis ; Obturator Internus and Pyriformis Muscles ; 
" Floor" of Pelvis, 33-47 

CHAPTER III. 

FEMALE ORGANS OF GENERATION. 

A. ExTEKXAL. Labia ; Perineum ; Hymen, &c. — Erectile Tissue. — The Vagina. — 

Glands of the External Organs — Abnormal Conditions. — Mammary Olaxds. 

B. Interxal. The Icterus ; Situation of ; Divided into Body and Cervix ; Axis of 

Unimpregnated Uterus ; Cavity of ; Fundus ; Surfaces and Borders ; Serous 
Covering of ; Broad Ligaments; Round Ligaments ; Vesico-Uterine Folds. — The 
Fallopian Tubes — Parovarium — Folds of Douglas. — Equilibrium of the Uterus, 

48-66 

CHAPTER IV. 

FEMALE ORGANS OF GENERATION (Continued). 

Of the Proper Tissue of the Uterus. — Of the Mucous Layer : its Structure and Glands, 
in the Body and Cervix. — Bloodvessels of the L^'terus. — Lymphatics and Nerves. — 
Malformations and Abnormal Conditions. — The Ovaries ; their Structure. — The 



VIU • CONTENTS. 

Graafian Vesicles and tlieir Development. — The Ovum. — Phenomena of Ovulation. 
— Formation of the Corpus Luteum. — The Corpus Luteum of Pregnancy distin- 
guished, 66-84 

CHAPTER V. 

MENSTRUATION AND CONCEPTION. 

The *' Rut" of Mammalia : Analogy between this and Menstruation. — The First Men- 
strual Period : Statistics of Duration of a " Period." — Quantity of the Discharge. 
— Menstruation a Hemorrhage. — Source of the Menses : various Theories regard- 
ing. — Pouchet's Theory examined ; Is the Mucous Membrane Shed? — Views of 
Kolliker, Coste, &c. — Duration of Child-bearing Epoch. — Cause of Menstruation. — 
Conception; — Composition of the Semen. — Spermatozoa and their Development. — 
The Function of the Germinal Vesicle. — How does the Semen reach the Ovum ? 

85-98 

CHAPTER VI. 

DEVELOPMENT OF THE OVUM. 

Disappearance of Germinal Vesicle. — Cleavage of the Yolk. — Development of the 
Blastodermic Vesicle. — ■" Serous" and " Mucous" Layers. — The Area Germinativa 
and Primitive Trace. — Formation of the Embryo ; of the Umbilical Vesicle and 
Omphalo-mesenteric Vessels ; of the Amnion ; of the AHantois and Umbilical Ves- 
sels ; of the Chorion. — The Liquor Amnii. — The Vitriform Body. — The Decidua: 
what is it ? — Decidua-Vera ; Reflexa ; Serotina. — Early Connection of Ovum with 
Decidua. — Th.e Umbilical Cord : Vessels ; Gelatine of Wharton, &c. — Knots on 
Cord. — The Placenta— in Birds : in Non-Placental Mammals : in Ruminants : in 
Man : Maternal and Foetal Surfaces of : Maternal Circulation in : Curling Arte- 
ries : Sinuses: Veins. — Foetal Portion: Arteries: Tufts or Villi : Veins. — Func- 
tions of the Placenta. — Structure of Villi, ...... 98-116 

CHAPTER YII. 

DEVELOPMENT OF THE EMBRYO AND FCETUS. 

Demonstration of Embryonic Structures. — Characteristics and Development of the 
Foetus at the Termination of each Month of Pregnancy, from the third onwards. — 
Dimensions of Mature Children. — Of the Presentation and Attitude of the Child 
in the Womb. — Causes of Cranial Presentation : Theories of " Physical Gravita- 
tion," "Volition" and "Reflex Action." — The Foetal Cranium: Sutures : Fonta- 
nelles : Diameters. — Definition of the term " Vertex." — Functions of the Foetus : 
Circulation: Respiration: Nutrition: Secretion, .... 117-140 

CHAPTER VIII. 

PREGNANCY : SIGNS OF PREGNANCY. 

Pregnancy. — The Gravid Uterus : Muscular fibres of : Muscular layers.— Change in 
fibres after delivery. — Development and Anatomical Relations of Uterus at various 
stages of Pregnancy. — Signs of Pregnancy. — Suppression of the Catamenia. — 
Digestive Disorders : Morning Sickness : Salivation.— -Kyesteine. — Changes in 
the Mammse : Pain : Enlargement : Secretion of Milk : Areola : Changes in 



CONTENTS. IX 

Nipple, and in Glandular Follicles: Secondary Areola.— Enlargement and Ex- 
ternal Appearance of Abdomen : Flattening in earlv months : Change in the 
Appearance of Umbilicus. — Diagnosis of other Abdominal Tumors. — Vaginal 
Examination: Color of Mucous Membrane : Vaginal False, . . . 140-154 



CHAPTER IX. 

SIGNS OF PREGXAXCT (Continued). 

Changes in the Os and Cervix Uteri : Frogressive Softening of : Characters of, at 
Various Stages. — Fosition of Os in Relation to Felvic Walls. — Digital Examina- 
tion or " Toucher." — Examination per Anum. — Quickening: Fa?tal Movements 
Observed, (a) by the Mother, (6) by the Accoucheur. — Ballottement or Reper- 
cussion. — Foetal Fulsation. — Funic Souffle. — Uterine Souffle : Theories as to its 
Production. — Stethoscopic Examination of Foetal Movements. — Division into 
Certain and Probable Signs. — Tabular Resume of the Signs of Pregnancy, 

155-171 

CHAPTER X. 

DURATION OF PREGNANCY SUPERFOETATION. 

Duration of Pkegxaxct : in Cows and Mares : in Wom.en. — Protracted Pregnancy : 
Cases of. — Difference in Rate of Development. — Mode of Calculating the Probable 
Time of Delivery : Calculation from last Menstruation to be corrected by Period 
of Quickening. — Supekfcetatiox : to be Distinguished from Superfecundation. — 
Proofs of the latter. — Tfrin Pregnancy in relation to this Subject.— Cases. — Con- 
clusions, ............ 17--1S4 

CHAPTER XI. 

PLURAL PREGNANCY EXTRA-UTERINE PREGNANCY. 

Plukal Pkegxaxct. — Mode of Impregnation. — Twins : Disposition of the Membranes 
and Placenta in: Diagnosis of: Relation of to Superfo?tation. — Triplets, <S:c. — 
Extka-Utekixe Pregxaxcy. — Varieties of: Ovarian: Tubal: Tubo-Ovarian : 
Abdomino-Tubal : Tubo-Uterine, kc. : Abdominal. — Causes of Extra-Uterine 
Pregnancy. — Development of the Ovum and its Coverings. — Sympathy of the 
Uterus. — Symptoms. — Progress of in Different Varieties : Rupture of the Sac : 
Peritoneal Inflammation : Discharge of Foetal Debris. — Terminations. — Treat- 
ment, 185-199 

CHAPTER XII. 

ABNORMAL DEVELOPMENT. 

Molar Pregnancy. — False Moles : from Vagina : Membranous Dysmenorrhoea : Fi- 
brinous and Hemorrhagic Casts of Uterus. — True Moles : Fleshy Moles : Hyda- 
tidiform Moles ; Their Pathology, Diagnosis, and Treatment. — ^Diseases of the 
Placenta, and their Effects. — Missed Labor. — Diseases of the Foetus. — ^Intra- 
uterine Fractures and Amputations : Efforts at Reproduction. — Monsters, 

199-211 



CONTENTS. 



CHAPTER XIII. 

DISEASES OF PREGNANCY. 

Disorders of the Digestive Fua^ctions. — Excessive Vomiting : Treatment of: 
Question of Induction of Premature Labor in. — Anorexia — Grastrodynia — 
Pyrosis — Constipation — Diarrhoea. — II. Disorders of Respiration. — Dyspnoea 
— Cough. — III. Disorders of the Circulation. — Condition of the Blood in Preg- 
nancy : Diminution of Red Corpuscles : Proportional Alteration in Fibrine and 
Albumen. — Supposed resemblance of the Phenomena of Pregnancy to those of 
Chlorosis. — Administration of Iron in Pregnancy. — Plethora. — Varicose Veins. — 
Hemorrhoids. — Thrombus of the Vagina, . . . . . . 211-224 



CHAPTER XIV. 

DISEASES OF PREGNANCY (Continued). 

IV. Disorders of Secretion and Excretion. — Ptyalism. — Interference with Func- 
tion of Kidneys and Bladder. — Retention of Urine : Mechanical or from Paralysis. 
— Albuminuria : State of the Blood in : Peculiarities of the Puerperal Form : Con- 
nection of with Puerperal Convulsions : Symptoms, Prognosis, and Treatment. — 
The Phosphatic Diathesis in Pregnancy. — Leucorrhoea and Grranular Vaginitis. — 
Ascites. — Drox3sy of the Amnion. — Hydrorrhcea. V. Disorders affecting Loco- 
motion. — Pelvic Articulations : Relaxation of: Inflammation of. VI. Disorders 
affecting the Nervous System. — Affections of the Special Senses. — Effect on the 
Moral and Intellectual Faculties. — Abdominal and Uterine Pain. VII. Dis- 
placements of the GrRAviD Uterus. — Prolapsus. — Anteversion and Anteflexion : 
Symptoms and Treatment of. — Retroversion ; how caused originally : Chronic 
and Acute Forms : Symptoms and Treatment of each ; Operation for the Reduc- 
tion of. — Oblique Displacements, 225-244 

CHAPTER XV. 

LABOR AND ITS PHENOMENA. 

Causes of Labor. — Maturity : Antagonism between certain Groups of Uterine Fibres : 
Brown-Sequard's Theory : Labor coincident with the Tenth Menstrual Period. — 
Forces by which Delivery is Effected : Nervi-motor Functions of the Uterus : 
Effect of Emotional Causes : Reflex Function of the Spinal Cord : Peristaltic 
Action : Auxiliary Force in the Muscles of Expiration. 

Stages of Labor. — Preparatory Stage. — First Stage : Labor Pains ; their Eft'ects on 
the Maternal Pulse and on the Uterine Souflle : False Pains : Mechanism of the 
Dilatation of the Os ; the Bag of Waters ; Effect of Longitudinal Fibres : Termi- 
nation of First Stage in Rupture of Membranes : Rigor : Show. — Second Stage : 
Change in Character of the Pains ; the " Caput Succedaneum :" Action of Volun- 
tary Muscles : Dilatation of the Perineum : Birth of the Head and Trunk.— Third 
Stage: " Dolores Cruenti :" Separation and Expulsion of the Placenta : Mechan- 
ism of this, . 244-260 



CONTENTS. XI 

CHAPTER XYI. 

MANAGEMENT OF NATURAL LABOR. 

Duties of the Accouclienr. — Preliminaiy Arrangements. — False Pains and their 
Trea,tment. — Armamentarium of the Accoucheur. — Position of the "Woman during 
Labor. — Digital Examination : Points to be Examined. — The Patient not to take 
to bed during the First Stage. — Preparation of the Bed, &c. — Abdominal Muscles 
to be called into play during the Second Stage. — Management of the Anterior 
Lip of the Os. — Obstacles arising from Eigid Os ; and from Non-Rupture of Mem- 
branes. — Use of Stethoscope. — Views regarding Support of Perineum. — Treat- 
ment if Laceration is threatened. — Causes of Laceration. — Birth of the Head. — 
Passage of the Trunk. — Treatment of Suspended Animation in the Child. — Liga- 
ture of the Cord. — Management of the Third Stage : Ci-ede's Method. — Application 
of Abdominal Bandage. — Treatment of the Woman after Delivery, . 260-275 

CHAPTER XVII. 

THE MECHANISM OF LABOR. 

Definition of Mechanism of Labor. — Difficulty and Importance of the Subject. — His- 
torical Sketch : Views of Sir Fielding Ould ; of Smellie ; of Saxtorph ; of Solayres 
de Renhac ; and of Naegele. — Natural and Faulty Presentations. 

Cranial Presentations : Occipito- Anterior and Occipito-Posterior Varieties. — First 
Position : Pelvic Obliquity : Occipito-Frontal Obliquity, or Flexion : The Head 
** at the Brim :" Examination of Fontanelles and Sutures. — Rotation : Causes of. 
— The "Presentation," or " Presenting Point." — The Caput Succedaneum. — The 
Chin leaves the Chest. — Further Descent and Birth of the Head. — Obliquity at 
the Outlet. — Moulding. — External Rotation or Restitution of the Head. — Second 
Position : the Converse of the First. — Resume of Mechanism in Occipito- Anterior 
Positions, 275-292 

CHAPTER XVIII. 

MECHANISM OF LABOR (Continued). 

Occipito-Posterior Positions. — Third Position ; Rotates into the Second, or may termi- 
nate with Forehead forwards. — Fourth Position ; Rotates into the First, or may 
terminate with Forehead forwards. — Artificial Rectification of these Positions. — 
Comparative Frequency of the Four Cranial Positions. 

Face Presentations. — Distinction between "Obstetrical" and "Anatomical" Face. — 
Mento-Posterior and Mento-Anterior Varieties. — Fourth Position ; Mechanism of. 
— Third Position. — First Position ; Rotates into the Fourth. — Second Position ; 
Rotates into the Third. — Relative Frequency of Facial Positions. — Operative 
Interference in. — Irregular Presentations. — Tabular Comparison of Cranial and 
Facial Positions, 393-313 

CHAPTER XIX. 

PELVIC PRESENTATIONS. 

The Practice of the Past. — The Pelvis a Natural Presentation. — Dorso-Anterior and 
Dorso-Posterior Positions. — Breech Presentation; Four Positions of. — First 
Position of the Breech : Rotation : Passage of the Buttocks : Descent and Birth 



Xll CONTENTS. 

of tlie Shoulders : Difficult Progress of the Head, and Mechanism of its Expulsion. 
— Second Position of the Breech. — Third Position of the Breech : Birth of the 
lower portion of the Trunk, and of the Shoulders : Rotation of the Face back- 
wards, and Mechanism of the Birth of the Head ; Exceptional Terminations. — 
Fourth Position of the Breech. — Special Risk of Pelvic Presentations. — Diag- 
nosis and Peculiarities. — Knee and Footling Cases. — Management of Pelvic Pre- 
sentations. — Nature of Assistance to he Rendered. — Use of the Fillet, Vectis, and 
Blunt Hook. — Indiscriminate Dragging on the Lower Limbs to be avoided. — 
Treatment of Case where Arms pass up alongside Head. — Management of the 
Funis. — Indications of impending Death of the Child. — Manipulation for effecting 
speedy Delivery of the Head. — Use of the Forceps, .... 314-329 

CHAPTER XX. 

TRANSVERSE PRESENTATIONS : COMPLICATED PRESENTATIONS. 

Transverse Presentations. — The Arm or Shoulder the Presenting Part. — Causes of. 
— Signs of, before and during Labor. — Premature Rupture of the Membranes to 
be avoided.— Dorso-Anterior and Dorso-Posterior Positions. — Determination of 
Exact Position by Observation of the Hand. — Probable Course of an Unaided 
Case. — Occurrence of Spontaneous Evolution. — Sj)ontaneous Expulsion. — Methods 
of Operative Assistance : Period of Labor to be selected : Cephalic Version : 
Podalic Version : Method of Combined External and Internal Manipulation : 
Special Difficulties. — Procedure Modified if Child Dead. — Compound or Com- 
plicated Presentations. — Hand and Head. — Hand and Foot, &c. — General 
Management of these, 330-343 

CHAPTER XXI. 

FUNIS PRESENTATION. 

"Presentation" and " Prolapse" of the Cord. — Relation of the Funis to other Pre- 
sentations. — Causes of. — Symptoms of at Various Stages of Labor. — Great Danger 
to Child. — Treatment : at first Expectant : avoid Rupture of the Membranes : 
Reposition by the Fingers ; by Mechanical Apj)liances : Various Repositoria 
described : Postural Method : Use of the Forceps : Turning, . . 344-355 

CHAPTER XXII. 

PREMATURE EXPULSION OF THE OVUM. 

Abortion ; Definition of. — Causes : in General Health : from Reflex Irritation : from 
Diseases of the Ovum : from Action of Oxytocics : from Affections of Neighboring 
Organs : from Mechanical Violence. — Tendency to Repeated Abortion. — Symp- 
toms at Various Periods. — Precursory Symptoms : Pains : Hemorrhage : to be 
distinguished from Delayed Menstruation. — Signs of Death of the Foetus. — Dis- 
tinction to be drawn between ''Threatened" and "Inevitable" Abortion. — Re- 
tention of the Ovum. — Expulsion of the Placenta. — Treatment : Preventive : 
Prevention when Abortion Threatened. — Expulsion to be Promoted when Inevit- 
able. — Management of Hemorrhage, and of the Placenta: Placental Forceps. — 
Treatment of a Woman after Abortion. 

Premature Labor. — Special Causes. — Treatment, 356-374 



CONTENTS. Xlll 

CHAPTER XXIII. 

HEMORRHAGE BEFORE DELIYERT. 

"Unavoidable" and "Accidental" Hemorrhage. — Placenta Pe^via ; Central and 
Lateral : Original Idea as to tlie nature of : Views of Roederer and Rigby. — 
Causes of Placental Presentation. — Symptoms : Hemorrhage before and during 
Labor : Examination from the Vagina. — Occasional Termination by Expulsion of 
the Placenta, with Cessation of Hemorrhage. — Symptoms and Termination of the 
" Lateral" Variety. — Treatment : General Measures : Use of the Plug or Tampon : 
Evacuation of the Liquor Amnii by Puncture of the Membranes or Placenta. — 
Turning in Placenta Prsevia : Passage of the Hand through the Placenta at one 
time Practised : Usual Method of Operation. — The Bi-Polar Method. — Artificial 
Extraction of the Placenta: Simpson's Statistics. — Partial Separation of the 
Placenta: Barnes's Views. — General Conclusions as to Treatment. — Accidental 
Hemorrhage ; more serious than is generally supposed. — Site of the Placenta. — 
Symptoms. — Treatment. — Use of Styptics in both Forms of Hemorrhage, 

374-390 

CHAPTER XXIV. 

HEMORRHAGE AFTER DELIVERY. 

Hemorrhage in the Third Stage of Labor. — Abnormal and Retained Placenta, and 
Irregular Uterine Contraction, as Causes of Flooding. — Post-Partum Hemorrhage. 
— Causes ; General and Local. — Symptoms ; External and Internal Hemorrhage : 
Examination of the Abdominal Walls: Examination by the Vagina: General 
Symptoms : Symptoms which indicate the approach of Death. — Treatment ; 
Prevention : Treatment during the Hemorrhage : Pressure and Friction over the 
Uterine Region : Effects of Bandaging : Effects of Passing the Hand into the 
Uterine Cavity : Aj)plication of Cold : Astringents to Internal Surface : Gal- 
vanism : El-got : Treatment by Plugging abandoned : Views in regard to Com- 
pression of the Abdominal Aorta : Application of the Perchloride of Iron and 
other Styptics : Objections to, and Arguments in favor of this Procedure : Dr. 
Barnes's Process. — Treatment directed to the General Condition of the Patient. — 
Effects of Rest and Position. — Reaction to be avoided after severe Flooding. — 
Secondary Post-partum Hemorrhage. — Transfusion: The " Mediate" and "Im- 
mediate" Processes : Dr. Aveling's Apparatus : Injection of Defibrinated Blood, 
and of Saline Solutions, 390-404 

CHAPTER XXV. 

INVERSION OF THE UTERUS. 

Varieties of Inversion : Three Stages of the Ordinary Variety. — Inversion of the Un- 
impregnated Uterus. — Inversion usually occurs during the Third Stage of Labor. 
— Causes : Dragging upon the Cord : Shortness of the Cord : Irregular Contraction 
of the Uterus : Connection of this Accident with Hour-Glass Contraction. — Effects 
of Paralysis of the Fundus. — Mechanism of the Displacement. — Symptoms : 
Peculiar Violence of the Shock : Hemorrhage : Absence of Tumor in Hypo- 
gastrium. — To be distinguished from a Fibrous Polypus. — Sensibility and Occa- 
sional Contractility of the Tumor. — Modes of proving the Absence of the Uterus 
from its Normal Situation. — Recurrence of Hemorrhage in Chronic Inversion. — 



XIV CONTENTS. 

Treatment : Ordinary Method of Replacement : Management of the Placenta if 
still Adherent : Management of more Difficult Cases : Compression of Tumor : 
Depaul's Instrument. — Chronic Inversion : Montgomery's Method of Reposition : 
Constriction of the Os must be Overcome : Effects of Sustained Elastic Pressure : 
Division of the Stricture : Removal by the Ecraseur, .... 405-416 



CHAPTER XXVI. 

RUPTURE OF THE UTERUS. 

Rupture during Pregnancy. — Rupture during Labor. — Partial or Incomplete Rupture. 
— Site, Extent, and Direction of the Laceration. — Reason of the Comparative 
Frequency of Cervical Rupture. — Is Rupture less Common in Primiparse ? — Effect 
of the Duration of Labor. — Causes — A. Mechanical : Sex ; Pelvic Deformity ; 
Faulty Presentation ; Pressure upon the Cervix ; Operative Violence ; Ergot ; 
Violent Uterine Action. — B. Reflex: Excitement of Cervix, &c. — C. Pathological; 
Cancer ; Rigidity of the Os ; Thinning or Partial Atrophy ; Softening ; Fatty De- 
generation. — Premonitory Symptoms : Localized Pain increased during Labor. 
— Signs of Rupture : Pain ; Hemorrhage ; Shock ; Recession of the Presenting 
Part. — Lacerations involving the Vagina. — Treatment. — Preventive Measures : 
Delivery by the Forceps or by Perforation : Extraction of the Placenta. — Hernia 
of the Intestine. — Treatment, if Foetus has escaped into the Peritoneal Cavity. — 
Further Management of the Case. — Treatment of Rupture of the Uterus in various 
Stages of Pregnancy, 416-427 

CHAPTER XXVII. 

DEFORMITIES OF THE PELVIS. 

Importance of the Subject. — Classification of Deformities. — Causes : Diseases affect- 
ing the Pelvis : Rachitis : Malacosteon. — Rickets and Malacosteon contrasted : 
Nature of the Brim Deformity characteristic of each.— Possibility of yielding in 
a Malacosteon Pelvis. — The Obliquely-Distorted Pelvis. — Deformities of the 
Cavity : Flattening of the Sacrum : Funnel-shaped Pelvis. — Distortion of the 
Outlet : Approximation of the Tuberosities of the Ischia : Projection Forwards of 
the Coccyx : Anchylosis of the Sacro-coccygeal Articulation. — Masculine Type of 
Pelvis. — Infantile Type. — Effect of Muscular Action in Producing Pelvic Distor- 
tion. — Spondylolisthesis. — Pelvis ^quabiliter-justo-Major, and justo-Minor. — 
Obstruction from Exostosis, Osteo-Sarcoma, and other Tumors : from Fractures of 
the Pelvis, and Morbus Coxarius. — Symptoms : Measurements of the Pelvis : 
Pelvimeters : Examination by the Fingers. — Effects of Distortion. — Difference 
between " Impaction" and "Arrest." — Treatment. — Prevention. — Circumstances 
-which call for the Forceps, Turning, Craniotomy. — Use of the Forceps in De- 
formed Pelvis. — Csesarean Section, 428-446 

CHAPTER XXVIII. 

THE FORCEPS. 

History of the Forceps. — Chamberlen's Forceps. — Invention of the Pelvic Curve. — 
The Short Forceps : Cases to which it is Applicable. — Reasons for preferring the 
Straight Forceps in most Cases. — Circumstances in which the Forceps is Re- 
quired. — Application of the Forceps : Conditions essential to Safety : Degree of 



I 



CONTENTS. XV 

Dilatation of tlie Os : Is it necessary to feel an Ear ? Membranes to be Rup- 
tured : Blades to be applied to tbe Sides of the Head : Forceps to be applied in 
tbe Opposite Oblique Diameter to that occupied by the Head of the Child. — The 
Operation : Introduction of the " Lower" and " Upper" Blades in the First Cra- 
nial Position : in the other Cranial Positions, 447-463 

CHAPTER XXIX. 

THE FORCEPS (Continued). 

Action of the Forceps : 1, by Compression ; 2, by Traction ; 3, by Double-Lever Ac- 
tion. — Mode of Extraction : Management and Direction of the Handles at various 
Stages of Delivery. — Delivery by the Forcej)S in Occipito-Posterior Positions : 
Rotation by the Forceps : Extraction with the Forehead Forwards. — The *' Long 
Forceps" : Reasons for Preferring the Pelvic Curve in this Operation : Descrip- 
tion of the Instrument : Cases in which the Long Forceps is applicable : Direc- 
tions for the Operation : Blades to be applied to the sides of the Pelvis : Mode 
of Introduction of the Lower and Upper Blades : Relation of the Blades to the 
Surface of the Cranium. — Use of the Forceps in Presentations of the Face. — Pro- 
cedure when the Head is retained after Expulsion of the Trunk. — Modifications 
of the Instrument : Ziegler's, Radford's, Assalini's and other Forceps, 464-4S4 

CHAPTER XXX. 

THE TECTIS ; FILLET ; BLUXT HOOK ; ETC. ; DECAPITATION. 

Discovery of the Vectis by Roonhuysen : Mode of Using the Yectis : Cases to which 
it may be Applied. — The Fillet ; a Contrivance of Ancient Origin : Applicable 
chiefly to Breech Cases — Tlie Blunt Hook. — The Crotchet : Precautions neces- 
sary in the Use of the Crotchet : The Gruarded Crotchet : Use of two Crotchets. — 
Decapitatiox ; Various Instruments for : Description of the Operation : Extrac- 
tion of the Trunk : Subsequent Extraction of the Head by the Various Methods 
of the Forceps, Crotchet, or Cephalotribe, ...... 485-494 

CHAPTER XXXI. 

TURNING. 

Various Methods of Turning : Turning as practised by the Ancients. — Podalic Ver- 
sion : Circumstances which call for, and Conditions favorable to the Operation . 
— The Operation in Detail : Choice of Hands ; Introduction of the Hand : Pas- 
sage of the Os : Seizure of a Foot or Knee. — Circumstances which render Turning 
Difficult : Difficulty in Seizing the Foot. — Child to be Turned Forwards. — Man- 
agement of the Case after Version. — Pelvic Version. — Cephalic Version. — Turn- 
ing in Contracted Pelvis : Degree of Distortion which may admit of Turning. — 
Turning contrasted with the Long Forceps, and as a Substitute for Craniotomy. — 
Special Difficulties. — Bi-manual or Bi-polar Version. — Processes of "Wigand, Lee, 
and Braxton Hicks, 495-511 

CHAPTER XXXII. 

EMBRYOTOMY. 

Conditions which warrant the Operation. — Ceaxiotomy. — Consists of various Stages. 
— Perforation : Varieties of Perforators : Method of, and Precautions to be Ob- 



XVI CONTENTS. 

served in Perforating : Cranial Contents to be Broken Up and Dislodged : Trac- 
tion to be now employed. — Use of tlie Crotchet : where to Fix it : Dangers of: 
The Guarded Crotchet. — The Craniotomy Forceps : Removal of the Vault of the 
Cranium : Protection of the Maternal Tissues. — Davis's Osteotomist. — The Scalp 
to be Preserved. — Turning after Craniotomy. — Canting the Base, after Removal 
of the Flat Bones, and bringing the Face Downwards. — The Cephalotribe : 
French and English Models : Cephalotripsy the Final Stage in the Operation of 
Craniotomy : Details of the Operation : May the Cephalotribe be used as a 
Tractor ? — Subsequent Extraction of the Trunk. — Craniotomy in Breech Delivery, 
after the Passage of the Trunk. — Embryulcia : Evisceration of the Foetus : appli- 
cable chiefly to Impacted Transverse Presentation. — Van Huevel's Forceps Saw. 
— Dr. Barnes's process of Cranial Section by the Ecraseur, . . . 511-528 

CHAPTER XXXIII. 

HYSTEROTOMY AND ALLIED OPERATIONS. 

History of the Operation of Hysterotomy. — Cases in which it is j ustifiable. — Maternal 
Mortality. — Different Results in British and Continental Practice. — Conditions 
■ favorable to Success. — The Operation and its Details : Duties of the Assistants : 
Closure of the Wounds. — After-Treatment. — Causes of Fatal Result. — Effect of 
Cold in preventing Peritonitis. — Repeated Success of the Operation in the same 
Cases. — GrASTROTOMY : Cases in which the Operation is required. — The so-called 
Vaginal Csesarean Section. — Symphysiotomy : History and Nature of this Opera- 
tion : Objections to it. — Stoltz's Operation of Pubiotomy. — Oastro-Elytrotomy ; 
reasons which have been urged in its favor. — Tabular Statement showing the 
Degree of conjugate Contraction at the Brim, which may be supposed to indicate 
respectively the Operations of the Long Forceps, Turning, Embryotomy, and the 
Csesarean Section, 528-540 

CHAPTER XXXIV. 

INDUCTION OF PREMATURE LABOR. 

History of the Subject. — Nature and Scope of the Operation. — Viability, or Non- 
Viability of the Child. — Conditions which justify the Operation. — Various 
Methods of Provoking Uterine Action : Ergot : Puncturing the Membranes : 
Separation of the Membranes by Hamilton's Method : Dilatation of the Cervix by 
Tents : Introduction of an Elastic Bougie or Catheter into the Uterus : Plugging 
or Distending the Vagina : The Method of Kiwisch by the Vaginal Douche : 
Cohen's Method by Intra-Uterine Injections : Dr. Barnes's Process, consisting of a 
"Provocative" and an " Accelerative" Stage: Oalvanism : Irritation of the 
Breasts. — Anatomical and Physiological Fitness of the Parts. — Constitutional 
Influences, 541-552 

CHAPTER XXXV. 

LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

Rigidity of the Os. — Use of Ansesthetics and of Belladonna. — Forcible Distension. — 
Incision if Os Occluded. — Effects of Uterine Displacement. — Abnormal Conditions 
of the Vulva and of the Vagina : Rigidity : Persistent Hymen : Cicatrices from 
Sloughing: Treatment of these Conditions. — Vaginal Thrombus. — Uterine Poly- 



CONTENTS. XVll 

pus ; Management of, wliere it obstructs Labor. — Ovarian Tumors. — Fecal 
Accumulation in the Rectum : Rectocele. — Distension of the Bladder : Cvstocele. 
— Stone in the Bladder an Occasional Impediment. — Herniae. — Other Tumors 
which may impede Labor. — Malignant Disease of the Canal, . . 553-564 

CHAPTER XXXVI. 

OBSTRUCTION DEPEXDIXG OX THE STATE OF THE OVUM. 

Hydrocephalus: Diagnosis of : Management of such Cases. — Spina Bifida. — Obstruc- 
tion from Ascites, Hydrothorax, and Distension of the Bladder. — Gaseous Disten- 
sion from Putrefaction. — Tumors springing from the Foetus. — x\nchylosis of the 
Joints, and Tntra-uterine Fracture. — Premature Closure of the Sutures. — Unusual 
Development of the Foetus. — Special Difficulties in Plural Pregnancy : Locked 
Twins. — Monsters which impede Delivery ; The Siamese Twins, and other Similar 
Cases. — Shortness of the Umbilical Cord as an Obstacle. — Dorsal Displacement of 
the Arm. — Thickness and Persistence of the Membranes, . . . 565-577 

CHAPTER XXXVII. 

UTERIXE IXERTIA AXD PRECIPITATE LABOR. 

Irregularities in the Progress of Labor ; often due to Intestinal Derangement. — 
Inertia : Influence of Temperament, Climate, Age, Emotion, Excessive Disten- 
sion, Premature Rupture of the Membranes, &c. — Influence of Irregular Uterine 
Action : Uterine Tetanus. — Wigand's Classification : Different Grades and Varie- 
ties of Inertia. — Treatment of Inertia ; if from Over-distension or Displacement 
of the Litems ; if from Intestinal Derangement : Various Modes of Exciting Reflex 
Uterine Energy : Stimulants as a rule to be avoided : Use of the Forceps in 
Inertia : Ergot : its Natural History, and Physiological Effects : Rules for its 
Use in Midwifery : Other Oxytocic Agents. 

Precipitate Labor : Causes obscure : Apparent Connection with Menstrual Ex- 
citement. — Labor may be Precipitate from Deficient Resistance. — Danger of Rup- 
ture and Laceration of the Uterus. — Tendency to Post-partum Hemorrhage. — 
Treatment : Empty Bowels : Opium : Sources of Reflex Irritation to be carefully 
avoided, 577-589 

CHAPTER XXXYIII. 

THE PUERPERAL STATE : LACTATIOX. 

Management of the Puerperal State. — The Lochia : Nature and Source of. — After- 
Pains : Treatment of. — The Lacteal Secretion : Milk Fever : Colostrum : The- 
Child to be put to the Breast at Fixed Intervals : Agalactia : Galactorrhoea ; Twa 
varieties of. — Management of Lactation : Effects of Over-Feeding. — Duration of 
Lactation. — Effects of Menstruation and Pregnancy upon Lactation. — Disorders 
of Lactation. — Inflammation and Abscess of the Mamma: Effects of: Treatment. 
— Excoriation and Fissure of the Nipples : Prevention of : Treatment of, 590-606 



XVlll CONTENTS 



CHAPTER XXXIX. 

THE NEWLY-BORN CHILD. 

Management of the Cord. — Clothing. — Cleanliness. — Light and Air. — Colostrum : Im- 
proper Use of Laxatives. — The Mother to Nurse if possible. — Selection of Hired 
Nurses ; their Diet and Regimen. — Causes of Difficulty in Sucking. — Congenital 
Malformations. — The Excretory Functions. — Diarrhoea: Simple or "Catarrhal," 
and Inflammatory or " Dysenteric" Varieties : Treatment of each. — Constipation : 
Management of. — Icterus Neonatorum. — Thrush. — Artificial Feeding : Substitutes 
for Breast Milk : Cow's Milk, Diluted and Sweetened : Nursing Bottles : Nurse to 
be procured if Child does not Thrive : Other Articles of Diet : Liebig's Food for 
Infants. — Weaning. — Dentition, ........ 607-623 

CHAPTER XL. 

PHLEMASIA DOLENS. 

The Puerperal State in its Relation to Disease. — Phlegmasia Dolens : Nomenclature. 
— Causes ; after Labor, and when Unconnected with Delivery. — Symptoms : 
Premonitory Signs : Pain : White Swelling : Tension : Heat : Constitutional 
Symptoms : The Limb Pits on Pressure during Convalescence : Loss of Power in 
the Limb. — Morbid Anatomy : Character of the Efi'used Fluid : Plugging of the 
Veins: State of the Lymphatics. — Pathology: Milk-Leg: Angeioleucitis : Crural 
Phlebitis : Experiments of M'Kenzie and H. Lee : Views of Tilbury Fox : Review 
of the Pathology of the Subject. — Treatment; Is Blood-letting justifiable? 
Blisters : Bandaging : Is Contagion Possible ? General Treatment to be directed 
as a rule to a Condition of Debility : Tonic Regimen : Antiseptic Remedies. — 
Causes of Protracted Convalescence, ....... 628-638 



CHAPTER XLI. 

PUERPERAL INSANITY. 

Nomenclature. — Normal Eflfect of Pregnancy on the Mind. — Insanity associated with 
Pregnancy, Labor, or Lactation. — True Puerperal Insanity. — Pathological Theo- 
ries. — Connection of Puerperal Insanity with Albuminuria. — Puerperal Mania ; 
to be distinguished from Phrenitis : it is essentially a Disease of Exhaustion. — 
Symptoms : Significance of a Rapid Pulse : Violence : Delusions. — Prognosis. — 
Puerperal Melancholia : Distinguishing Characteristics : Probable Termina- 
tions. — Treatment: Prevention: Blood-letting to be avoided: Management of 
the Digestive Functions : Emetics : Vascular Sedatives : Nervous Sedatives ; 
Opium, Hyoscyamus, Chloral, &c. : Diet and Regimen : Seclusion and Restraint : 
Treatment during Convalescence. — Tendency to Recurrence after Subsequent 
Labors, 638-651 

CHAPTER XLII. 

PUERPERAL ECLAMPSIA. 

Definition. — Connection between Eclampsia and Acute Bright's Disease. — Eclampsia 
from other Morbid Conditions. — Effects of Pregnancy on the System. — Period of 
Explosion. — Symptoms : Premonitory Signs : OEdema, Albuminuria, Cephal- 



CONTENTS. XIX 

algia, &:c. — Phenomena of the Fit : Period of Tonic and Clonic Convulsions, and 
of Coma. — Pathology: Albuminuria:- Decomposition of Urea, and Formation in 
the Blood of Carbonate of Ammonia : Effects of Pressure on the Renal Veins : 
Detection of Albumen in the Urine. — Morbid Anatomy. — Effect of Labor Pains. — 
Maternal and Foetal Mortality. — Prognosis : in Eclampsia Gravidarum, Partu- 
rentium, et Puerperarum. — Treatment: Prophylaxis: Use of Acids: Purgatives 
and Diuretics : Induction of Premature Labor : Treatment during the Fit : Blood- 
letting : Chloroform : Chloral : Obstetrical Treatment at Variou^ Stages of 
Labor : Acceleration : Rupture of the Membranes : LLse of the Forcei^s, 652-666 



CHAPTER XLIIL 

PUERPERAL FEVER AND ALLIED AFFECTIONS. 

Perjjlexing Nature of the Subject. — Puekpeeal Fever : Does a Sx^ecific Puerj)eral 
Poison really exist ? — Should the term " Puerperal Fever" be retained? — Special 
Peculiarities of the Puerperal State. — Puer^jeral Septicaemia : Mode of Septic 
Poisoning. — Connection with certain Zymotic Influences ; Erysipelas, Smallpox, 
Scarlet Fever, &c. — Connection with Post-Partum Inflammations. — Pueepeeal 
Peritonitis ; May exist independently of Puerperal Fever ; Symptoms of an Or- 
dinary Attack ; of the more Severe form. — False Peritonitis. — Pcerpeeal Metri- 
tis ; of less Frequent Occurrence : Symptoms. — Uterine Phlebitis : Symptoms at 
first Obscure: Secondary Abscesses in the Later Stage : Tissues chiefly involved. 
Vaginitis ; Sthenic and Asthenic. — Inflammation of the Uterine Lymphatics, 

667-676 

CHAPTER XLIV. 

PUERPERAL FEVER, ETC. (Continued). 

Question of Contagion : Septicsemic Infection : Other Specific Poisons. — Are Inflam- 
matory Cases Contagious ? — Histoiy of Ei^idemics. — Symptoms of Puerperal 
Fever. — Morbid Anatomy : Malignant and other Varieties Contrasted : Lesions 
of other Organs : Pathological Appearances no Indication of the Virulence of the 
Attack. — Evidence of a Change of Type in Puerperal Fevers. — Treatment : All 
Varieties to be Treated as if Contagious : Recorded Results of Blood-letting and 
Purging : Grooch's Treatment : Connection of Metastatic Inflammation with 
Thrombosis and Embolism : Uterine Phlebitis : Purulent Formations : Effect of 
Emetics ; Calomel and Opium ; Turpentine, Blisters, and External Applications ; 
Tonic and Stimulant Treatment : Tapping the Peritoneum : Prophylactic Treat- 
ment : Cleanliness : Use of Antiseptics, ...... 677-695 



CHAPTER XLV. 

PELVI-PERITONITIS : SUDDEN DEATH IN PUERPERAL PERIOD : 
ANESTHESIA. 

Pelvi-Peritonitis. — Inflammation of the L^terine Appendages. — "Fulness," ''Hard- 
ness," and " Tumor." — Pelvic Cellulitis : Anatomy of the Pelvic Cellular Tissue. 
— Bernutz on Pelvic-peritonitis. — Diagnosis of Pelvic Cellulitis and Pelvi-perito- 
nitis. — Engorgement of the Uterus. — Detection of Pus : Fluctuation. — Treatment : 
Alleviation of Pain : Application of Leeches, Poultices, Fomentations, &c. : 



XX CONTENTS. 

Methods of Promoting Absorption ; Mercury ; Iodine ; Counter-Irritation : The 
Operative Treatment of Abscess. — Peri-uterine Hsematocele. — Sudden Death in 
Puerperal Period : Embolism of Pulmonary Artery. — Arterial Embolism. — En- 
trance of Air into Veins. — Anaesthesia : Various Anaesthetic Agents : Effects of 
Chloroform on the Blood, and on the Progress of Labor : Disadvantages of Chlo- 
roform : Modern Practice, ......... 695-710 

APPENDIX, 711-718 

INDEX, 719-732 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Pelvis of the female guinea-pig, ......... 25 

2. The same ; showing the separation of the bones during parturition, . . 25 

3. Diagram showing the direction in which the uterine contents gravitate in 

the Mammalia generally, ......... 28 

4. Diagram showing the oscillatory movement referred to (Matthews Duncan), 32 

5. External surface of right os innominatum, ....... 34 

6. Internal surface of the same bone, ........ 34 

7. Sacrum and coccyx — anterior surface, ........ 34 

8. 9. Male and female pelves contrasted, as seen from before (Quain), . . 37 
10, 11. Male and female pelves contrasted, as viewed in the axis of the brim 

(Quain), • 38 

12. Internal surface of female pelvis, showing — 1, 2, greater and lesser sacro- 

sciatic ligaments ; 3, 4, greater and lesser gaps of foramina, ... 40 

13. Diagram showing the inclination and axis of the true pelvis, ... 41 

14. Diagram showing the axis of the parturient canal, ..... 42 

15. Interior of pelvis, showing the ischial planes, ...... 43 

16. Outlet of the female pelvis, 44 

17. Infantile pelvis, ............ 46 

18. External organs, partially dissected (Kobelt), ...... 50 

19. Showing the relative position of the pelvic organs, ..... 52 

20. Dissection of the lower half of the female mamma during the period of lacta- 

tion (Luschka), ........... 56 

21. Structure of a lobule of the mammary gland, ...... 57 

22. Ultimate glandular vesicles of the mamma, ...... 57 

23. Diagram showing relative position of pelvic viscera (A. Farre), ... 59 

24. Profile section of the uterus, 60 

25. Transverse section of the uterus, ........ 60 

26. The OS uteri, 60 

27. Pelvic organs in situ, viewed in the axis of the brim (after Schultze), . . 62 

28. Anterior view of the uterus and its appendages (Quain), .... 63 

29. Posterior view of the uterus and its appendages (Quain), .... 63 

30. Diagrammatic view of the uterus and its appendages as seen from behind 

(Quain), ............. 65 

31. Tubular glands of uterus (E. H. Weber), 67 

32. Tubular gland of the uterus (Coste), 68 

33. Relation of tubular glands to muscular tissue of uterus (Coste), . . 68 

34. Termination of tubular glands on mucous surface of uterus (Coste), . . 69 

35. Tubular orifices of uterus (Sharpey), 69 

36. Double vagina and uterus (after Busch), ....... 73 

37. Bifid uterus, ............ 73 

38. Diagram showing the layers of the Graafian vesicle and the contained 

ovum, . . . . . . . . . . . . .76 

39. Diagrammatic representation of the ovum, as it escapes from the Graafian 

vesicle, ............. 76 

40. Development of Graafian vesicles in the sow, ...... 77 

41. Ovary dissected to show the structure of the Graafian vesicle at various 

stages (Coste), 80 

42. Structure of the corpus luteum (Coste), ....... 81 

43. The corpus luteum of simple ovulation, . . . . . . .82 

44. Corpus luteum in the third month of pregnancy (Montgomery), . . 83 



XXll 



LIST OF ILLUSTRATIONS 



FIG. 

45. Corpus luteum in the sixth month of pregnancy (Montgomery) 

46. Cori^us luteum at the period of delivery, ..... 

47. Tumefaction of the uterine mucous membrane during menstruation (after 

Coste), 

48. Spermatozoa and vesicles of evolution, .... 

49. 50, 51. Successive stages of the cleavage of the yolk, 

52. External surface of the ovum, showing the area germinativa 

53. Diagram showing the earliest formation of the embryo, 

54. Diagram showing early stage of development, . 

55. Further development of the ovum, ..... 

56. Development in a more advanced stage, .... 

57. Completion of the amnion and formation of the umbilical cord, 

58. Diagram showing Hunter's theory as to the formation of decidua 

59. Formation of decidua ; first stage, . . . . . 

60. Formation of decidua completed, ..... 

61. Flap of decidua refiexa turned down, disclosing the ovum, 

62. Foetal surface of the placenta, ...... 

63. Maternal surface of the placenta, . . 

64. Section of the placenta, . . . . , . 

65. Foetal villi of the placenta, 

Q6. Ultimate foetal villi, highly magnified, . . . 

67. Ovum opened, and embryo partly dissected, 

68. The same embryo, further dissected, ..... 

69. Posterior view of branchial apparatus, &c., 

70. Posterior view of foetal heart, , . . ... 

71. Dissection of an ovum in situ, about the fortieth day, 

72. Attitude of the foetus in utero, ...... 

73. Uterine cavity at the fifth month, . . . - . 

74. Upper surface of foetal cranium, ..... 

75. Diameter of the foetal cranium, . . . . . 

76. Circulatory apparatus in the foetus, . 

77. Diagram illustrating Goodsir's theory of foetal nutrition, . 

78. Fibre-cells of the unimpregnated and gravid uterus contrasted 

79. External muscular layer of uterus, . . . . 

80. Internal muscular layer of uterus, ..... 

81. Degeneration of fibre-cells after delivery, .... 

82. Diagram showing development of uterine cavity (after Schultze) , 

83. Areola, and secondary areola of pregnancy (seventh month), 

84. Cervix uteri (primiparse), twenty-fourth week, , 

85. " (pluriparpe), twenty-fourth week, . 

86. " (primiparse), thirtieth week, . 

87. " (pluriparae), thirtieth w^eek, , 

88. " (primiparae), at full term, 

89. " (pluriparse), at full term, 

90. 91. Apparent shortening of cervical canal, 

92. To calculate the duration of pregnancy (after Schultze), 

93. Diagrammatic representation of partition in twin pregnancy (1st var 

94. Twin pregnancy (2d variety), ..... 

95. Hydatidiform degeneration of ovum, .... 

96. Intra-uterine amputation and attempted reproduction, 

97. Retroflexion of the womb about the 16th week (Schultze), 

98. Retroversion about the 12th week (Schultze), . 

99. Parturient canal completed by the obliteration, of the os and 

100. Distension of the perineum (after Hunter), 

101. Alleged inversion of the placenta in the third stage, 

102. Normal position of the placenta in the third stage, 

103. Mode of digital examination, ..... 

104. Cranial planes as they engage in the brim, 

105. First cranial position, ...... 

106. Internal lateral surface of pelvis, .... 

107. Lateral obliquity of the head advancing in the axis of the brim 

108. The head approaching the outlet : First position, 

109. First position as seen from above (Schultze), 

110. Diagrammatic representation of successive stages of the first position, 



PAGE 

83 
83 



iety), 



LIST OF ILLUSTRATIONS, 



XXlll 



Fia. 

111. 

112. 

113. 

114. 

115. 

116. 

117. 

118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 
131. 
132. 
133. 
134. 

135. 

136, 

139. 

140. 

141. 

142. 

143. 

144. 

145. 

146. 

147. 

148. 

149. 

150. 

151. 

152. 

153. 

154. 

155. 

156. 

157. 

158. 

159. 

160. 

161. 

162. 

163. 

164. 

165, 

166. 

167, 

168, 

169, 
170 
171 
172 
173 



Transverse presentation 
Spontaneous expulsion 



Second cranial position, ..... 

Second cranial position at tlie outlet, 

Third cranial position, ..... 

Fronto-anterior termination of the third position. 
Fourth cranial position, ..... 

Fourth cranial position at the outlet, 
Diagram showing successive stages of rotation and 
facial position, ...... 

First position of the breech, .... 

Birth of the breech, ...... 

Birth of the shoulders, ..... 

Arm displaced upwards, ..... 

Birth of the head, ...... 

Fourth position of the breech, .... 

Artificial delivery of the head in breech cases, . 
Transverse presentation : Dorso-anterior, 
Dorso-posterior, 
First stage. 
Spontaneous expulsion : Second stage. 
Spontaneous expulsion : Third stage. 
Case of complicated presentation, 
Braun's repositorium, ..... 

Cells of fatty and healthy decidua, • 
Placental forceps, ...... 

Dr. Aveling's apparatus for transfusion. 
Partial inversion (after Matthews Duncan), 

137, 138. Successive stages of inversio uteri, 
Thomas's method of reducing chronic inversion (after 

Rachitic pelvis, ...... 

Malacosteon pelvis, ...... 

Isabel Redman's case, ..... 

Obliquely distorted pelvis, .... 

Flattening of the sacrum, ..... 

Funnel-shaped pelvis, ..... 

Exaggerated sacral curvature, .... 

Pelvic exostosis, . . .... 

Baudelocque's callipers, and Coutouly's pelvimeter, 

Lumley Earle's pelvimeter, .... 

Manual pelvimetry (Ramsbotham), . 

Showing effect of pressure on cranial presentation. 

Showing effect of pressure after turning, . 

Sketch of Chamberlen's forceps (Rigby), . 

Straight forceps for ordinary use, 

Davis's forceps, ....... 

Hodge's forceps, .... . . 

Wallace's forceps, ...... 

Smith's forceps, . . . •. 

Elliot's forceps, ....... 

Robertson's forceps, ...... 

Simpson's forceps, ...... 

Introduction of the lower blade. 

Introduction of the upper blade, 

The forceps applied, 

Forceps for application at the brim, . 

C D, curve of abnormal promontory ; B A, Carus's 
Barnes, . . . . . 

Introduction of long pelvic-curved forceps. 

Diagram, showing various stages in the introduction 
(lower blade), 

Introduction of the first blade in the dorsal position, 

Introduction of the second blade in the dorsal position. 

Instruments introduced and locked in the dorsal position 

Long forceps applied, .... 

Ziegler's forceps, 



deliverv in 



Thomas) 



of 



the lono; 



the 



first 



Modified 



PAGE 

290 
291 

294 
296 

298 
298 

307 
317 
318 
319 
320 
320 
322 
329 
333 
333 
336 
336 
337 
343 
352 
359 
372 
403 
405 
406 
416 
431 
432 
432 
433 
434 
434 
434 
437 
439 
440 
441 
445 
445 
448 
451 
452 
453 
454 
455 
456 
456 
457 
, 461 
, 462 
, 463 
, 468 



from 



forceps 



473 
475 

476 

477 
478 
479 

480 

482 



XXIV 



LIST OF ILLUSTRATIONS. 



174. Radford's forceps, 

175. Assalini's forceps, modified by Dr. Jolin Brunton, 

176. The vectis, 

177. Whalebone fillet, 

178. The blunt hook, 

179. The crotchet, . 

180. Podalic version, 

181. Turning by the noose or fillet, 

182. Malacosteon pelvis, 

183. Bi-manual version : first stage, 

184. Bi-manual version : second stage, 

185. Bi-manual version : third stage, 

186. Simpson's perforator, 

187. Hodge's craniotomy scissors, 

188. Guarded crotchet, 

189. Craniotomy forceps, . 

190. Braun's cranioclast, . 

191. 192. Meigs's craniotomy forceps, 

193. Osteotomist, .... 

194. Simpson's cephalotribe, 

195. French cephalotribe, 

196. Dr. Matthews Duncan's cephalotribe 

197. Hysterotomy, .... 

198. Barnes's uterine dilators, , 

199. Uterine polypus as an obstacle to delivery 

200. Ovarian tumor obstructing delivery, 

201. Double-headed monster, 

202. Double monster, .... 

203. Head represented descending directly in the axis of the br 

204. Head rej)resented descending in the position described by 

205. Lateral obliquity of the head advancing in the axis of the 



im, 

Naegele, 

brim, 



PAGE 

483 
483 
486 
488 
489 
490 
499 
501 
506 
508 
509 
510 
514 
515 
516 
516 
517 
517 
518 
522 
523 
524 
532 
551 
558 
559 
573 
574 
712 
712 
713 



Note. — The forceps figured at page 483 as " Assalini's Forceps," should have been 
described in the text as "Assalini's Forceps modified by Dr. John Brunton." 



A SYSTEM OF MIDWIFERY 



CHAPTER I. 

INTRODUCTORY. 

History of Michcifery — Hippocratic Era — Arabian School — Amhroise Par^ — Mau- 
riceav — English Midwifery — Objections to the Practice of Midicifery con- 
sidered — Comparatire Anatomy of the Pelvis — The Pelvis a Tube through 
which the Product of Conception Passes. — Parturition in the Primates: in the 
various Races — The Erect Posture the Main Cause of Comparative Difficulty 
in Human Species — The Human Pelvis a Curved Canal — Separation of Pelvic 
Articulations during Labor — Midwifery Defined. 

The History of Midwifery is to the student of that art a subject not 
only interesting, but also in some degree instructive. To trace from 
their earliest development, whether in the crude ideas of ancient times, 
or in the hasty generalizations of an epoch not far distant from our own, 
the growth and maturity of theories which we now believe to be in 
accordance with the truth, is indeed in itself an attractive pursuit; and 
the student has his reward in the thorough mastery he thus obtains over 
details, which can scarcely be effected by the mere dogmatism of ordi- 
nary teaching. 

For various and evident reasons, however, the history of i\\Q obstetric 
art cannot be embraced fittingly within the limits which must be fixed 
for matter purely introductory to the study of a great practical subject. 
Not even in outline, then, will a consecutive history of midwifery be 
attempted ; but, as reference w411 in the sequel be not unfrequently made 
to the doctrines and practice of the past, a few^ sentences may here be 
devoted to the consideration of the midwifery of certain epochs, in view 
of the influence which these may be supposed to exercise on the practice 
of the present day. 

From the earliest records, more or less authentic, which seem to throw 
light upon the subject, it would appear that the practice of midwifery 
was in the first ages entirely in the hands of women. If we may judge, 
however, from the fact that a law was passed in Athens, at a very early 
period, by which women were absolutely prohibited from practising 
physic in any of its branches, we are entitled to assume that the art had 
2 



18 INTRODUCTORY. 

not in the main prospered in their hands. It is in the Hippocratic 
writings that we find the first trace of a profound intellect and a truly 
scientific mind being applied to the observation of the phenomena of par- 
turition. The works, indeed, on this subject, which are attributed to 
Hippocrates, are, for the most part, passed over as unauthentic by 
modern critics; but there can at least be no doubt that they were written 
before Aristotle, at the latest, we may assume, about 400 b. c. The 
head, according to the former authority, is the only natural presentation, 
and when the child either lies across, or presents by the feet, the woman 
cannot be delivered. Observe the effect of this aphorism. The head 
being thus assumed to be the only presentation in which the natural 
forces could effect delivery, it follows, as the natural corollary of this 
proposition, that one of the chief aims of operative midwifery must be to 
convert breech and footling, as well as transverse presentations, into 
presentations of the head. The contemplation of such a state of practice 
is too horrible to dwell upon. His graphic illustration of the olive in the 
neck of the oil jar is familiar to all, and demonstrates to perfection that 
it can, in its long diameter, be easily passed through ; " but," he adds, 
" if the long diameter of this oval body be thrown across, either the 
bottle will break or the olive will be crushed." It is strange, indeed 
almost incredible, that, having recognized the form of the foetus while in 
the womb, as this simile clearly shows, he should have failed to perceive 
that an oval body, be it olive or foetus, may pass by either end of its 
long diameter. Overlooking this fact, he established a rule of practice, 
which obtained in after ages, as there is every reason to believe, for a 
period little short of two thousand years, at what expense of maternal 
and foetal life it is impossible to compute. From this early period we 
must also date the operation of craniotomy, for the performance of which 
quite intelligible rules are given. 

This error of Hippocrates was corrected by Aristotle and subsequently 
by Celsus ; but it is to the latter that the credit in this matter is usually 
ascribed by the commentators, as his words are clear and free from am- 
biguity. This is manifest from the following sentence alone, extracted 
from the instructions given by him for the management of transverse 
cases: " Medici vero propositum est, ut eum manu dirigat, vel in caput, 
vel etiam in pedes ^ si forte alitor compositus est." 

Some four or five hundred years later, a careful compilation of all 
that had been written up to that time on the subject of midwifery was 
made by ^tius. Among the untoward circumstances detailed as causes 
of difficult labor, he mentions a narrow pelvis, the presence of polypi, 
and obliquity in the position of the womb. He states, further, that an 
anchylosis of the ossa pubis at their point of junction is a fertile cause 
of difficult labor, by preventing the separation which would otherwise, 
he supposes, occur ; and that distention of the rectum or bladder may 
constitute a mechanical impediment to delivery. He observes, also, that 
difficult labor is due as well to a faulty condition of the child as of the 
maternal parts. If the child, or any of its parts, were unduly large, 
labor was presumed to be impeded by the fact that the motions and leap- 
ing of the child (supposed, even in comparatively modern times, to con- 
tribute greatly to its delivery), were thereby interfered with. Many 



MIDWIFERY AMONG THE ANCIENTS. 19 

other points of interest and of practical importance are referred to by 
him, one or two of which may be noticed. We have here, for example, 
in a chapter, "De Foetiis Extractione ac Exsectione," which he takes 
from Philumenas, the first indication of the speculum vaginse, in an in- 
strument which he recommends for the purpose of separating the external 
parts, in order to bring the cause of obstruction into view. We have 
also a perfect description of the crotchet (uncinus attractorius) ; and in 
his description of a method of delivery by the application of two crotchets 
— one to each side of the head — we cannot fail to observe that the me- 
chanical principle of the midwifery forceps was- not only then adopted in 
practice, but was thoroughly understood by the author, and brought him 
very near to the discovery of the forceps of modern times. And, finally, 
we have here the operation of turning in cases of difficult cranial pre- 
sentation recommended, in terms which place it beyond a doubt that the 
procedure indicated is in all respects identical with what of late years 
has been introduced in similar cases, as a novelty and an improvement in 
modern practice. The credit of the discovery and demonstration of the 
Fallopian tubes was claimed by Galen, but there is no doubt that they 
were described at a still earlier period than the epoch now in question 
by Rufus Ephesius, who lived in the reign of Trajan (^circa, A. J). 110). 
The last writer on this subject of the old Greek school was Paulus ^gineta, 
to whose works little originality can be attributed. 

The favor in which literature and the sciences were held by the Arabs 
evidently exercised a most beneficial influence in the development of the 
Arabian School of Midwifery. The name of Rhazes, a physician of 
Bagdad towards the end of the ninth century, is associated with the 
discovery of the fillet. About a hundred years later a very remarkable 
and voluminous series of works on midwifery and allied subjects was 
given to the world by Avicenna, a physician of Ispahan. His works 
consist for the most part in a confirmation of the leading views of the 
Greek school, and as they enjoyed an extraordinary popularity in 
Europe, as well as in Asia, it was by this channel mainly that the errors 
of the ancients were diffused throughout the world. The fundamental 
error of Hippocrates he adopts in a modified degree. All presentations, 
says he, except the head, are preternatural: the head ought, therefore, 
to be brought, in all such cases, into the natural position, but, should 
this be impracticable, we may deliver by the feet. He recommends in 
certain cases the use of the fillet, which, when used for extraction, is to 
be fixed over the head ; and, should this fail, the forceps is to be applied 
to the head and extraction then attempted, while as a last resource only 
are the perforator and crotchet to be employed.^ A reference to this 
passage makes it perfectly clear that the instrument alluded to is essen- 
tially the midwifery forceps ; while the fact that the author nowhere 
describes the instrument as a novelty warrants us in the belief that, about 
the tenth century, or possibly at an earlier period, the use of this impor- 
tant instrument was familiar to the Arabian physicians. In the works 
of a later writer, of the eleventh or twelfth century,^ the forceps then 

' See the chapter, " De regimine ejus, cujns partus fit difficilis causa magnitudiins 
foetus." 

2 Albucasis or Alsaharavius. 



20 INTRODUCTORY. 

used in midwifery is described and delineated. It is represented under 
two different forms, the misdach and the almisdach. In the Arab ori- 
ginal in the Bodleian Library at Oxford to which Sraellie refers in his 
learned introduction, the former of these is described as straight and the 
latter as curved, but in the Latin version both are described as circular 
and full of teeth. 

From this period, until the invention of printing in the middle of the 
fifteenth century diffused a knowledge of the writings of the ancients 
throughout the civilized world, our art seems to have made but little 
progress. Indeed, we may even say with truth, that, after the decline 
of learning in the East, the art of midwifery, as practised in Europe, 
was far inferior to what obtained amono; the Arabians and even amono; 
the later Grecian winters. This we may easily understand if we reflect 
that Hippocrates was the text-book in the hands of all, and that his 
errors continued to influence the practice of midwifery until the dawn of 
science, after the dark ages of our art, dissipated in some measure the 
mists of ignorance and superstition. 

In 1518, Dr. Linacre, physician to Henry VIII., obtained, through 
his interest with Cardinal Wolsey, letters- patent constituting a corporate 
body of regular physicians in London. This foundation of the Royal 
College of Physicians of England marks the period at which midwifery, 
for the first time in this country, was brought within the domain of 
science. It must be confessed, however, that the earliest efforts of 
English authors contributed but little to the advancement of the art, as 
founded upon true scientific principles. The first English work on the 
subject was a translation of Eucharius Rhodion, by Dr. Raynalde, under 
the title of " The Byrthe of Mankynde."^ That this work was held in 
no little repute on the Continent is evident from the fact that it had been 
translated from the original High Dutch, not only into Latin, but also 
into Dutch, French, Spanish, and other languages. And yet, when we 
examine it critically, we find that, except as a literary curiosity, it 
scarcely merits our attention. Not only does he indorse the famous 
blunder of Hippocrates, by saying that we should turn the child to the 
natural position even when the feet present, but he boldly promulgates 
another error when he says that, when the child presents in the natural 
way by the head, the face and foreparts of the foetus are towards the 
foreparts of the mother. In most other respects his views are but 
copies from the ancient writers. The same remark may be made with 
reference to the productions of his contemporaries, as we find doctrines 
which are essentially the same promulgated in the collection of mono- 
graphs, memoirs, and reproductions from ancient and modern sources, 
by Israel Spachius, known as the " Gynyeciorum Commentaria,''^ a col- 
lection familiar to all who have investigated this subject. A very super- 
ficial study of this compilation will suffice to show that even the more 
flagrant errors of the ancients were still systematically taught ; and 
therefore we are bound to conclude that the Hippocratic aphorism of 
turning by the head in breech presentation had, up to this period, been 
all but universally adopted in European practice, even although that 

1 London, 1565. 2 Basel, 1586. 



AMBROISE PARE. 21 

error had been to a great extent corrected by the later Greek and the 
Arabian writers. It is not, then, too much to assert, as we have done, 
that the blunder of Hippocrates, so frequently alluded to, was the rule 
of practice for little less than 2000 years after his death. 

In this collection, however, there is one work which we must mention 
with more respect — that of the illustrious Ambroise Pare — of whom 
Smellie says no more than is his due when he terms him " the famous 
restorer and improver of midwifery." The revival of anatomical study 
under Vesalius, and the numerous dissections w^hich had been made of 
pregnant women by him and b}^ his follower Columbus, had already" cor- 
rected many of the anatomical and physiological errors, which, being 
time-honored, were therefore considered to be respectable, and were 
generally admitted to be true. The belief in these doctrines being thus 
sapped by the logic of facts, the whole rotten superstructure began to 
crumble away, and from this epoch modern midwifery may be said to 
have had its origin. It required a mind of no ordinary power and 
energy to be the pioneer in this new^ path ; but it requires no critical 
analysis of the work of Par^ to show that the great surgeon was a great 
master, and that scientific Midwifery as w^ell as Surgery had at last 
found a fitting modern exponent. Par^ advises turning by the feet in 
difficult cranial presentations ; but if this cannot be done, he recommends 
craniotomy, or delivering by the crotchet — which instrument he directs 
us to fix, by the method of ^Edus, in the orbit or mouth, or below the 
chin. He frankly confesses, that although he has carefully studied the 
position of the foetus in utero, he has been unable to come to a satisfac- 
tory conclusion as to what is to be considered the normal position ; while, 
as regards the causes of difficult labor, he dilates at some length, and on 
the whole with considerable accuracy. After pointing out with great 
clearness the serious nature of the impediment caused by cicatrices, the 
result of former midwifery accidents, he enumerates the various posi- 
tions of the foetus which interfere with or prevent delivery, and concludes 
by noting the bad efiects of uterine inertia, and of premature escape of 
the waters. 

At this period, the Parisian school was undoubtedly the first in the 
world ; and as all the leading surgeons there practised midwifery, the 
practice as well as the theory of obstetrics became rapidly developed. 
Guillemeau, surgeon to the French king, and a pupil of Ambroise Par^, 
further developed the theories of his master ; but the book Avhich seems 
to have exercised the greatest influence was the remarkable one of 
Mauriceau, " Sur les Maladies des Femmes grosses, et de ceux qui sont 
accoucLeas." This author gives by far the best account which, up to 
his day, had appeared of the phenomena of labor as observed by the 
accoucheur. He criticizes with some asperity the views of Columbus, 
which, however, we find to be, at least as regards the position of the 
child in the womb, infinitely more correct than his own. The following 
are his conclusions on this point : Up to the seventh or eighth month, 
the child is situated in the centre of the womb, the head being towards 
the fundus and the face looking directly forwards. About this period 
an important change takes place in its position, which, if it happens 
sooner, is attended with danger. The weight of the head and upper 



22 INTRODUCTORY. 

part of the infant having now become relatively greater, it causes the 
child to turn forwards [faire la culhute en devant), so that the face is now 
turned directly backwards to the promontory of the sacrum. This doc- 
trine is simply an amplification of the views of Hippocrates on this 
point ; and it must be admitted, even in the present day, that the greater 
relative frequency of breech and irregular presentations in cases of pre- 
mature delivery, lends some apparent confirmation to the idea. He 
repudiates the view formerly entertained, that the child, by its own 
instinctive or automatic movements, aided in any way in efi'ecting its 
expulsion, and recognized not only the contractility of the uterine tissue, 
but also the supplementary expulsive force which is derived from the 
muscles of the abdominal walls, these acting, as he shows, with greater 
effect upon the rounded back and nates of the child than they could upon 
the head, did the head present. Mauriceau seems also to have some 
indistinct and inaccurate idea of the rotation which occurs in the pelvis ; 
for, after stating that, in footling cases, it is necessary that the face in 
its descent should look backwards, he gives directions for turning the 
child during its descent, unless this has already taken place, so as to 
make the heels look directly forward. 

Any one who may wish to pursue this subject further will find ample 
and most interesting material in the works of Peu, Dionis, Deventer, 
La Motte, Puzos, Roederer, Levet, and others. In many of these, new 
errors are developed, such, for example, as the undue importance given 
to uterine obliquities by Deventer and his followers, who supposed them 
to be a frequent cause of tardy labor. The re-discovery of the midwifery 
forceps by the Chamberlens, about the middle of the seventeenth century, 
marks another and most important epoch ; but this will fall to be more par- 
ticularly considered when we come to discuss the forceps and its uses." 

The interesting subject of the mechanism of parturition was inaugu- 
rated little more than a hundred years ago by Sir Fielding Ould, of 
Dublin, and this, too, is another important era in the history of mid- 
wifery. To trace the successiv^e steps, from the faint glimmering of the 
truth which perplexed the shrewdness of Ould, and baffled the astuteness 
of Smellie, to the full development of the modern theory as it was laid 
before the scientific world in the celebrated essay of Naegele, would lead 
us upon ground which for the present we must avoid. In the sequel, 
and at the proper place, such of the historical facts as are essential to 
the comprehension of this subject will be briefly noted. ^ 

It seems, on first sight, a paradox that the practice of midwifery 
should involve, in the human species, the supervision of a function which 
is purely physiological, and should be claimed by its professors as an 
important branch of the healing art. So difficult, indeed, has this 
problem been of solution, that many, from Rodericus a Castro downwards, 
have asserted that the practice of the art was derogatory to professional 
dignity, and an unnecessary interference with a natural process. " Obste- 
triciam artem nee exercui nee exercere volo," wrote one of these ; and 
there is reason to believe that the words find an echo even now. We need 
scarcely pause to refute the former of the two objections. We presume 

' For a critical analysis of this subject, see an essay hy tlie author " On the Me- 
chanism of Parturition." London, 1864. 



OBJECTION'S TO THE PRACTICE OF MIDWIFERY. 23 

Ave may hold it as proved that, from the very earliest times, women re- 
quired and obtained assistance at the period of delivery. This assistance 
was afforded, as we have already seen, by persons of their own sex; and 
that there is a fitness in this no one will gainsay. If we may judge, 
however, from the Athenian laws, we may assume that the practice of 
obstetrics did not prosper in the hands of women ; but it must be con- 
fessed that there is evidence enough in the works of Arsinoe and Cleo- 
patra, to prove that some of them, at least, Avere quite familiar with the 
doctrines and practice of their age. And it must be conceded further, 
in these days when women are knocking so loudly, and with such impor- 
tunity, at the portals of professional recognition, that if the mantle of 
Mesdaraes La Chapelle and Boivin could be made to fall on the shoulders 
of their sisters of the present generation, female delicacy would be saved 
many a rude shock, and the cause of science would in no sense suffer. 
But what do they say who repudiate the general practice of the art ? 
Women, they assert, should in their hour of need be attended by women, 
and only in the case of difficulty or danger should the male accoucheur 
be summoned. The answer to this simply is, that the assistance of the 
latter would, under such circumstances, be of no value whatever, as with- 
out a knowledge of the healthy or normal standard, which can only be 
attained by the constant observation of the natural process, ignorance, 
not skill, would be called upon to act. To the full as rational would it 
be to ask one to compute distance or space who had no knowledge of the 
standards of lineal measurement or capacity. Certainly, in the present 
day, Men are required for the practice of midwifery, skilled in medicine and 
the applied sciences, and who do not think of their dignity, any more than of 
their ease and comfort, when their services are in this matter required. 

In regard to the other objection, we must, of course, admit that partu- 
rition is a physiological function. But, in the discharge of this function, 
there exist in the human species peculiar conditions which exercise, as 
compared with the lower animals, a special influence upon the progress 
and issue of labor. What these conditions are will be best understood 
by a reference to one or two points in comparative anatomy, which reveal 
certain analogies, the appreciation of which clears away many difficulties, 
and a knowledge of which is, in point of fact, almost essential to the 
student of midwifery. 

At an early period of mammalian development, two rods or bars of 
cartilage may be observed passing, more or less obliquely, from the 
dorsal towards the ventral surface of the embryo near its caudal ex- 
tremity.^ The two parts are separated at their dorsal extremity, where 
they embrace the vertebral column ; while in front, in most cases, they 
meet and form a symijliysiB. This is the primitive pelvis. As the pro- 
cess of development goes on, the cartilage of each side, widening to a 
great extent superiorly, ossifies from three centres, by the union of which 
the OS innominatum is formed, the two lower segments — ischium and 
pubis — leaving a gap between them, the obturator or thyroid foramen. 
If we except the Cetacea and Sirenia, in which the pelvis is almost 
rudimentary, these characteristics are common to the whole mammalia. 

^ See Flower's " Osteology of the Mammalia." London, 1870. 



24 INTRODUCTORY. 

The innominate bones are firmly united above to the sacral vertebrae, and 
usually below to each other at the symphysis; and this union, firm as it 
is, is greatly strengthened by a double ligamentous union of considerable 
strength between the sacral and caudal vertebrae on the one hand, and 
the ischia on the other. This is familiar to anatomists as the greater and 
lesser sacro-sciatic ligaments, which are sometimes replaced by bone — as 
in the sloth. 

The mammalian pelvis, then, by the union of the two innominate bones 
and the sacrum, forms, with some exceptions, a complete circle or girdle 
of bone ; or, in other words, a short canal or tube which has two outlets. 
Of these, the anterior is called the inlet or hrim, which is marked more 
or less distinctly by a line which runs from the top of the symphysis 
pubis to the first sacral vertebra. The axis of this is — owing chiefly to 
the obliquity of the innominate bones — never parallel to the vertebral 
column, but diverges from it more or less widely, according to what is 
termed the "inclination" of the brim. The outlet looks backwards or 
downwards according to the position of the animal, and is bounded in the 
dorso-ventral diameter by the caudal vertebrae on the one side, and the 
lower margin of the pubic symphysis on the other, and laterally by the 
great sacro-sciatic ligaments (or bones) and the converging borders of the 
ischia. As the planes of brim and outlet are never quite parallel, the 
axis of the pelvis is consequently more or less of a curve. 

A careful study of the form, and extent of development, in the various 
mammalian groups, shows clearly that, as in other parts of the skeleton, 
the ever- watchful provision by nature of means to an end is here strik- 
ingly exemplified. In the Cetacea, where there are no pelvic limbs, the 
pelvis is composed of two slender bones ununited inferiorly, the chief use 
of which seems to be to afford an attachment for the crura of the penis 
and clitoris. In the Armadillo, it is strong and powerful, to aid in the 
support of the exo-skeleton. In the Carnivora, the ilium and ischium 
are in a straight line and of nearly equal length, the pelvis being thus 
elongated and narrow. The symphysis is long, includes part of both 
pubis and ischium, and, in adult animals of this class, is usually closed 
by anchylosis. In the Seals, the pelvis is small and of a different form 
from the terrestrial Carnivora, the ilia being small, and the ischial and 
pubic bones long and slender. The symphysis is small and loose, admit- 
ting of being widely separated during parturition. 

In many of the Insectivora, the symphysis is absent, the bones being 
widely separated in the middle line. The pelvis of the mole, for example, 
is long and narrow, and its axis is nearly parallel with the vertebral 
column. The ischium, as well as the ilium, is united to the sacrum by 
anchylosis, and the brim is so narrow that, there being no union at the 
symphysis, the pelvic viscera lie external to the cavity, and parturition 
takes place beneath rather than through the pelvic canal. In the Ro- 
dentia the ischial and pubic bones are always largely developed, flat, and 
diverging posteriorly, while the symphysis is long and usually osseous. 
The guinea-pig is an exception, as here the union remains ligamentous, 
and admits of free opening during labor. 

In the order Ungulata, the Pecora or true ruminants are characterized 
chiefly by the great development of the ischial tuberosities, forming a 



COMPARATIVE ANATOMY OF PELVIS. 



25 



well-marked conical process which is diverted outwards on each side. 
The symphysis is long, and includes a considerable portion of the ischia, 
and large epiphyses are observed, forming the articulating surfaces. 
These parts ultimately become fused by anchylosis. In the Perisso- 
dactyla, the greater expansion of the ilia, as seen in a marked degree in 
the skeleton of the elephant, indicates, at first sight, an approach to the 
human type ; but the narrowing of the pelvis at the level of the aceta- 
bula, and the comparatively small ischial and pubic portions, at once 
dispel the illusion. 

The Edentata have the pelvis more or less elongated, and the ischia 
largely developed. In almost all, the ischia are directly connected with 
the vertebral column by one or more osseous bridges, the single one in 
the sloth passing from the ischial spine, and thus representing the lesser 
sacro-sciatic ligament. This is carried to the greatest extent in the 
Armadillos, where a long unyielding tube is formed by the coalescence 
of the ilium and ischium on the one hand, and a considerable number of 
sacral and pseudo-sacral vertebrie on the other. In most of the Eden- 
tates, not only the sacro-iliac articulations, but also the symphysis pubis, 
are anchylosed. 

The Marsupiata and Monotremata are characterized by the great 
development of the ischial and pubic bones, and the development in the 
tendon of the external oblique muscle of the "marsapial" bones. 

The facts here cited will suffice to show that the pelvis, in the various 
groups into which the mammalia have been divided, is formed so as to 
suit the requirements of the individual. The mode of locomotion, be it 
leaping, running, or swimming, is revealed to the anatomist by an exami- 
nation of the pelvic bones, and in every case it will be seen that the pre- 
ponderance of ilium, ischium, or pubis, is due to the necessity which 
exists for certain mechanical arrangements, by which alone can the re- 
quired muscular power be effectively applied to the bony levers. The 
pelvis is also an efficient support 
to the organs which are usually °' ' 

contained within it, and especially 
to those which are connected with 
the function of generation. 

The obstetrician, however, 
looks at the pelvis from a differ- 
ent point of view. In it he sees 
the osseous canal through which 
the product of conception must 
pass in the act of parturition. 
lie sees in it also the protect- 
ing framework Avhich shields 
the generative viscera from the 
effects of shock or injury. And, 
above all, he studies it as a 
structure which, if abnormal, 
may seriously obstruct the pro- 
cess of parturition. Let us look, then, for a moment, before quitting the 
subject, and from this standpoint, at the pelvis of the mammalia. Through- 




Fig. 1.— Pelvis of the Female Guinea-Pig. 
Fig. 2.— The same; showing the separation of the 
bones during parturition. 



26 INTRODUCTORY. 

out the whole series, irrefragable evidence is afforded that the pelvis is 
designed with a direct reference to the propagation of the species ; and 
we find, moreover, that, on the approach of labor, certain modifications 
of structure which then occur, clearly prove that nature prepares the parts 
beforehand for the new function. Thus, in the Chevrotains, a group of 
little deer-like animals, formerly associated with the musk-deer, the ischia 
in the males join the elongated sacrum by ossification of the sacro- 
sciatic ligaments, but in the females the latter retain their normal struc- 
ture. In the prolific guinea-pig, again, ^ the pelvis is long and laterally 
compressed, the passage being much narrower than the diameter of the 
head of the mature foetus. About three weeks before parturition, the 
inter-pubic ligaments become soft and extensile, so that during labor the 
innominate bones separate from each other at the symphysis, the sacro- 
iliac joint thus becoming on each side a hinge. After this process, the 
symphysis quickly returns to its former state, and in a few days presents 
only a little thickness and mobility. The young of the guinea-pig are 
far advanced at birth ; some of the deciduous teeth are shed in utero, 
and they run about and begin to eat soon after they see the light. 

In the cow, as the period of purturition approaches, a relaxation of 
the pelvic ligaments also occurs, but the process here is different.^ The 
gradual upward curve and posterior projection of the ischia causes the 
well-marked dorsal projection of their tuberosities, which appear promi- 
nently on the rump, projecting on each side and above the coccygeal 
vertebrae. By this elevation of the ischia, the sacra-sciatic ligaments 
become a means of support to the pelvis, so that their action is inverted 
as compared with the corresponding structure in the human pelvis. As 
the period of utero-gestation approaches its termination, these ligaments, 
as well as those of the sacro-iliac joints, become relaxed to such an extent 
that the sacrum is observed to sink downwards between the innominate 
bones, so that the ischial tuberosities become very prominent, and rela- 
tively elevated. The object of this is manifestly to render parturition 
easier. Did this, indeed, not occur, there can be little doubt that in the 
cow the difficulties of labor which occasionally arise would be of much 
more frequent occurrence. It is interesting to observe, as the probable 
cause of dystochia in those animals, that, owing to the greater curve of 
the sacrum, the axis of the pelvis is necessarily more strongly curved 
than usual, and in this respect approximates to the human type. 

If we now turn to the Primates, we shall be able to show, by a com- 
parison of the human race with those of the mammalia which stand 
nearest to it in the scale, that the process of childbirth must be more 
difficult and more obnoxious to serious hindrance than in any — even the 
highest — of the other mammalia. In all the Simiadie, the ilium is, as 
compared with man, much elongated. ••' Each os innominatum in the 
adult male gorilla," says Owen, " is one foot three inches in length, that 
of man being seven inches and a half; the breath of the ilium is eight 
inches and a half, that of man being six inches." In the lower forms — 
as the baboons and monkeys — the ilium is even longer, relatively to 

• Owen — " Comparative Anatomy and Physiology of tlie Vertebrates." 
2 Todd's " Cyclopc-edia of Anatomy and Physiology." Supplement. 1859. Art. 
''Pelvis." 



COMPARATIVE ANATOMY OF PELVIS. 27 

the other bones of the pelvis, than is here described. The ilia are 
nearly in a straight line with the vertebral column, and the inferior 
rami of the ischia are directed almost horizontally inAvards, entering into 
the formation of the pubic symphysis, which, in the ape tribe generally, 
may be more properly called the ischio-puhic symphysis. The form of 
the cranium is the familiar and ready test, not only in distinguishing be- 
tween man and the lower animals, but also between the various races of 
mankind. It is peculiarly interesting to us, however, to observe that a 
careful examination of the pelvis will also supply equally reliable infor- 
mation. The chief peculiarities of structure which are exhibited in the 
case of the highest of the Simiad^e have just been noticed. In addition, 
we observe that the depth both of the true and false pelvis is much 
greater than in the human race, that the sacrum is much narrower, espe- 
cially in the chimpanzee, that the ischial spines are more closely approxi- 
mated, and, above all, the antero-posterior measurements at the brim 
prevail greatly over the transverse. 

Were we to compare the highest ape with the lowest man, Ave would 
find the following broad points of distinction. In the ape, a pelvis Avith 
the brim much more inclined, its antero-posterior exceeding its transverse 
measurement ; a bending of the pelvic brim at the ilio-pectineal eminence 
forming an angle of about 120°, called the iUo-pnhic angle — a charac- 
teristic which, without exception, distinguishes the lower animals possess- 
ing pelves ; a marked elongation of the ilia ; and a parallelism of the 
symphysis with the vertebral axis. In man, less inclination of the brim, 
and a marked preponderance of the transverse over the antero-posterior 
diameter; the boundaries of the brim, here alone in the animal kingdom, 
on one plane ; great expansion of the ilia, as compared with their length ; 
and the symphysis forming an angle with the vertebral column. The im- 
port of this great gap in development is evident, and has its explanation 
in the adaptation of man alone of all created beings to the fully erect 
p)08ture. 

The descriptive anatomy of the human pelvis will form the subject of 
another chapter. AVe shall here glance only at its special functions, in 
so far as they may be held to differ from those of the lower animals. In all 
the other mammals the habitual and only natural position or posture of 
the animal is prone, — the dorsal surface being superior, the ventral in- 
ferior. In those in which pelvic limbs exist, the weight of the posterior 
or pelvic portion of the trunk alone is transmitted through the pelvis to 
the cotyloid cavities, and thence transferred to the heads of the thigh 
bones. In man, the whole weight of the body above the pelvis is directly 
transmitted to it by the imposition of the last lumbar vertebra on the base 
of the sacrum, from which again it is transferred when the body is erect 
to the femora, and in the sitting position, to the tuberosities of the ischia. 
To enter upon an analysis of the mechanical laws upon which this de- 
pends would be suitable to a work on animal physics, but we must here 
confine ourselves to such points only as are germane to our subject. 

The sacrum — which is relatively much broader and stronger in man 
than in any of the lower animals — is the part which receives the weight 
of the trunk, the centre of gravity being, according to Weber, 8.7 milli- 
meters above the sacro-lumbar joint, or just above the pelvic arch. It 



28 



INTRODUCTORY. 



has been compared by Cruveilhier to a wedge, by others to the key-stone 
of an arch, and by Sir Charles Bell to the heel of a mast, — the base of the 
vertebral column being fixed so that the interval between the innominate 
bones may be looked upon as the step in which the vertebral mast is 
socketed and mortised. In any case we may consider the weight as be- 
ing transmitted from the sacro-iliac joints in one of two directions : in 
the erect posture, it passes through the irregular, thick, and curved but- 
tresses which are formed by this portion of the ilia directly to the coty- 
loid cavities ; in the sitting posture it passes, on a posterior plane, from 
the same joints almost directly downwards to the tuberosities of the ischia. 
The sacrum is thus described as forming the common culminating point 
of two arches — viz., the cotylo-sacral or standing arch, ^nd the ischio- 
sacral or sitting arch. The extremities of these arches are prevented 
from starting outwards, not by abutments as in the ordinary architectural 
arch, but by connecting links or ties, which are represented in the cotylo- 
sacral arch by the horizontal pubic rami, and in the ischio-sacral by the 
united ischio-pubic rami. This complicated arch acts also by preventing 
inward pressure, in the erect posture, by the head of the femur ; while 
shock is in a great measure obviated by the oblique manner in which the 
sacrum is placed — the sacro-sciatic ligaments preventing the movement 
of the coccyx upwards and backwards, while the ilio-lumbar ligaments 
prevent the corresponding motion of the base of the sacrum downwards 
and forwards.^ The expanded external surfaces of the ilia give attach- 
ment to the mass of the glutei muscles, more powerful, for obvious rea- 
sons, in man than in any other animal. 

But the pelvis has, in addition to the elaborate mechanical functions 
above shortly alluded to, a new and special function thrown upon it in 
man. This is the support of the pelvic viscera, including the organs of 
generation. These latter being larger and heavier in the female, and in 
view also, no doubt, of the requirements of the pregnant state, nature 

here makes special provision for their accom- 
Fig. 3. dation, in the greater capacity and modified 

form to which we shall afterwards advert. In 
the lower animals, the abdominal viscera, and, 
to some extent, also the pelvic viscera, are 
supported by the lower abdominal wall. The 
contents of the pregnant uterus, therefore, 
gravitate downwards in the direction of the 
arrow in Fig. 3, and, under no circumstances, 
does the weight of the uterine contents press 
into the cavity of the pelvis. Even in the 
feimiadae, where the erect posture is to some 
extent assumed, the greater inclination of the 
pelvic brim prevents the gravitation of the 
uterus and its contents into the true pelvis. 
In a pregnant woman, on the other hand, not 
only are the pelvic viscera proper supported 




Di^igram showing the directi m 
in which the uterine contents gra- 
vitate in the Mammalia generally. 



' Dr. Matthews Duncan, in his "Researches on Obstetrics," 1868 (p. 55), shows 
more correctly, that the weight is transferred from the sacrum to the cotyloid cavity, 
not directly, but indirectly tlirough the agency of the posterior ilio-sacral ligaments. 



COMPARATIVE ANATOMY OF PELVIS. 29 

by the structures which form the floor of the pelvis, but some support is 
indirectly aflbrded to the abdominal viscera under certain circumstances. 
In the pregnant state, the uterus and its contents gravitate to a consider- 
able extent downwards and backwards in the axis of the brim. 

The necessity which thus exists for efiicient pelvic support to these 
parts has not been overlooked. "Were the pelvis a simple tube, with 
the inlet looking upwards, and the outlet downwards, it is obvious that 
no efficient support could be afforded. But the tube, far from being 
straight, is in a woman strongly curved — so strongly, indeed, that a line 
drawn so as to represent the axis of the brim and the long axis of the 
uterus (which we may here assume to be identical) will not fall within 
the plane of the outlet at all, but behind it, somewhere about the centre 
of the coccyx. By this curve in the pelvic axis, the lower part of the 
sacrum, the coccyx, the sacro-sciatic ligaments, the levatores ani and 
coccygei muscles, and the fascial and soft structures form a ^rm floor ^ by 
which, in a normal and healthy condition of the parts, perfect support 
is given to the structures of which we have spoken. But this manifest 
advantage is obtained at the price of increased difficulty in the act of 
parturition. This difficulty is, no doubt to a very great extent, compen- 
sated for by the development of the sub-pubic arch, a peculiarity of the 
human species which is but imperfectly developed in the lower animals. 
"Without this, indeed, and that shortness of the symphysis in woman 
which admits of the widest development of the arch, labor would be 
always difficult and often impossible. 

The function of the pelvis being thus in every case a complicated one 
is so in the human female in an especial degree. The unyielding nature 
of the structure, essential to the effectual support of the trunk, and the 
curving of its cavity for the reasons above stated, render child-bearing 
in this instance exceptionally liable to dangers of various kinds, and 
thence arises the necessity for that thorough professional training which 
can alone engender confidence and develop skill. 

The comparative facility with which parturition is effected in the lower 
races of the human species has also been used as an argument against 
the practice of midwifery. In reference to this objection, on which we 
need not dwell, there can be little doubt that the effect, in certain classes 
of society, of modern and luxurious habits, exercises no inconsiderable 
influence upon the physiological phenomena of parturition. i\.s regards 
the difference between the races, many very interesting facts have been 
revealed by the researches of Vrolik, Weber, and others, but there is 
still in this direction a wide field for orio;inal inve3tio;ation. The facts 
which already have been disclosed point to the important conclusion that 
there subsists in the various races a remarkable coincidence between the 
prevailing form of the skull and the diameters of the pelvic brim, and 
that, consequently, the adaptation of the foetal skull to the pelvic passage 
during labor must be greatly facilitated. Weber's conclusions, drawn 
from the examination and measurement of a considerable number of 
crania, are, that we may admit, as the general rule, subject however to 
numerous exceptions, that the oval shape is most common in Europeans, 
the round shape in the American aborigines, the square shape in the 
Asiatic or Mongolian type, and the oblong in the Negro races. As re- 



80 INTRODUCTORY. 

gards the assumed facility of labor in the latter, there is every reason 
to believe that this has been greatly exaggerated, and that cases of dys- 
tochia, though comparatively rare, are yet not unfrequent. If the pelvis 
were the same in size and proportion in them as in Europeans, the in- 
ferior cranial development would afford an obvious explanation of the 
alleged fact of habitually easy labors. So far, however, from this being 
the case, we have just seen that the form of the pelvis corresponds to the 
shape of the head. An examination of Negro, Bushman, and other 
pelves, shows in many instances a remarkable degradation of type, such 
as a vertical direction of the ilia, and their elevation at the posterior- 
superior spines, narrowness of the sacrum, and acuteness of the sub-pubic 
angle. An occasional peculiarity in some of the lower races, and one 
which appears even more to approach to the ape type, is the preponder- 
ance of the conjugate over the transverse diameter of the brim. But 
they who have asserted that the lower races referred to simulate in this 
respect Apes rather than Europeans have gone too far, as is clearly 
proved by the measurements given in Wood's admirable article on the 
pelvis in Todd's Cyclopaedia, already quoted. From this, it appears 
that while the transverse diameter may, in the higher Simiac'se, measure 
less than the conjugate by one and a half to two inches, the difference in 
cases of oblong pelvis in Negroes is merely fractional, and that the type 
is in every case far more closely allied to the European than to the 
Simian, where the conformation of the pelvis is such, even in the highest 
forms, that its marked peculiarities are appreciated at a glance. 

Whether the pelvic articulations in women are, or are not, divaricable 
during parturition, is a question obviously of great practical importance 
to the accoucheur. Involving, indeed, as it does, practical considerations, 
this is a subject, the study of which might here be considered premature. 
But, in view of the facts which have just been stated in relation to the 
comparative anatomy of the pelvis, this vexed question may, we believe, 
be noticed with more advantage at this stage than at any other. In so 
far as a study of the physiological phenomena of labor in the lower 
animals can throw light upon the subject, we have already seen that 
separation may take place to a very considerable extent at the symphysis, 
as in the guinea-pig (see Fig. 2), or at the sacro-iliac joint, as in the 
cow. So far, then, analogy points to the possibility of such a separation. 
Besides, anchylosis of either one joint or the other, common as it is in 
the louver animals, is known to be, in the human species, an extremely 
rare occurrence. 

Actual observation, again, by men of such undoubted authority as 
Pare, Levret, Smellie, and many others, has proved, beyond all possi- 
bility of doubt, that in women who have died during the parturient 
period, separation of the bones, in some cases at the symphysis and in 
others at the sacro-iliac joints, has been seen and recorded. Few prac- 
titioners of extended experience have failed to observe that women 
occasionally complain, it may be either before or after labor, of pain in 
the neighborhood of these joints, difficulty or inconvenience in walking, 
and, more rarely, a grating or crepitant feeling, arising obviously from 
an unwonted motion of the articulating surfaces upon each other ; from 
which we may conclude that separation may, to some extent at least, 



MOBILITY OF PELVIC ARTICULATIONS. 31 

occur. Cases such as have been detailed by Soemmering — where the 
bones at the sacro-iliac joint have been found separated to the extent of 
an inch — have been supposed to be the result of disease and deposit 
of pus. 

Admitting, then, that some separation does occasionally occur, are we 
to assume that this is to be held as abnormal and morbid, or admitted as 
one of the essential physiological phenomena of human parturition ? It 
is, we suppose, now universally believed that, during the last months of 
pregnancy, the cartilaginous and other structures forming these joints, 
to be hereafter described, become softened, as if by serous infiltration. 
The synovial membranes, indistinct before, now become capable of 
demonstration ; and, more important, perhaps, than all, the tissues be- 
come thickened, while the ligaments of the joints are relaxed. The effect 
of such thickening must, of necessity, be, like ivy roots in a wall, to force 
the bones asunder and, consequently, to increase the pelvic diameters. 
If, however, there is, as has been asserted, a yielding much more exten- 
sive than this, such motion may be assumed to occur in one of two ways : 
either by a separation at the pubes, involving a hinge motion of the 
sacro-iliac joint, as in guinea-pigs, or by a movement of the sacrum be- 
tween the ossa innominata, involving a hinge motion of the symphysis, as 
in the cow. As regards the first of these, a careful examination of the 
circumstances under which it may occur, would seem to indicate that a 
separation of the pubic bones to the extent even of an inch would add 
very little to the diameters of the brim, and would contribute least of all 
to the smallest or conjugate diameter. The analogy which the frequent 
yielding of the symphysis seems to reveal, gave rise, about the end of 
the last century, to an operation consisting in the artificial section of the 
symphysis in cases of obstruction at the brim — a mode of procedure 
which Dr. Matthews Duncan seems to think has been in these days too 
completely consigned to oblivion. 

The other method in which the pelvic capacity may be increased by a 
movement of these joints, is by the motion of the sacrum between the 
ossa innominata, somewhat as it has been shown to occur in the cow.^ 
From what has already been said, it may be inferred that to compare the 
sacrum either to a wedge or a key-stone is very far from accurate. We 
have seen that this bone, besides its union with the sacrum by means of 
intervening cartilage, is maintained in its position by the ilio-lumbar and 
sacro-sciatic ligaments — the former preventing, or rather strictly limiting, 
along with other forces, the downward and forward movement of the pro- 
montory ; while the latter limits, in like manner, the upward and back- 
ward motion of the coccyx. Now, these ligaments share in the general 
relaxation of the pelvic structures towards the end of gestation ; and 
thereby we may assume, that the movement or oscillation on its trans- 
verse axis, of which the sacrum is capable, and which is said by Zaglas 
to be about a line in the unimpregnated condition, is, in the last months 
of pregnancy, considerably increased. The manner in which this oscil- 
lation of the sacrum takes place in different positions of the woman is 
clearly shown by Zaglas. " In the erect position, the promontory of 

^ Barlow. Monthly Journal of Medical Science, January, 1854. 



82 



INTRODUCTORY 



Fig. 4. 



the sacrum is not in the position of greatest projection into the brim of 
the pelvis, but the reverse; and, consequently, the apex is in its forward 
position, diminishing the outlet and relaxing the sacro-sciatic ligaments. 
When the body is bent forward, on the other hand, the base of the 
sacrum is protruded into the brim, the apex is tilted upwards, the sacro- 
sciatic ligaments put on the stretch, and the outlet of the pelvis conse- 
quently enlarged. These movements take place, ordinarily, both in man 
and woman, in defecation, etc., but in her they are of greatest interest 
and importance in the function of parturition." ^ The backward motion 
of the coccyx has also the effect of producing lateral widening of the 
pelvis, by bringing a wider part of the base of the sacrum between the 
ilia. This, of course, supposes some gliding motion in the sacro-iliac 

articulation, or, at least, yielding of 
the parts. The experiments of MM. 
Giraud and Ansiaux seem to show 
that, in contracted pelves, the move- 
ments take place to an even greater 
extent, as if nature were doing her 
utmost to obviate the disastrous ef- 
fects of pelvic deformity. Dr. Mat- 
thews Duncan, in his admirable essay 
on this subject, points out, with great 
clearness, the very remarkable man- 
ner in which these alterations cor- 
respond with the phenomena of the 
progress of the child in parturition. 
In the first stage of labor, for ex- 
ample, when the head is passing 
through the brim, the woman prefers 
the standing, sitting, or reclining posture, in which the brim of the pelvis 
is, as we have seen, kept open at the expense of the outlet (see Fig. 4) ; 
but in the second stage she bends her body forwards, draws up her legs, 
and calls into action the abdominal muscles, which act by tilting up the 
symphysis ; in a word, her posture and voluntary efforts are now pre- 
cisely those which may most eftectively increase the conjugate diameter 
of the outlet by tilting back the coccyx. To the motion of the sacro- 
coccygeal joint, which is universally admitted, we need not at present 
specially advert. 

From these and other facts disclosed up to the present time, we con- 
clude: " 1st. That in the last months of pregnancy, a marked relaxation 
and softening of the pelvic articulations take place. 

2d. That, as the result of this modification in structure, an increased, 
though limited, mobility is permitted, which tends to facilitate labor. 

3d. That in addition to the movement of the sacrum on its transverse 
axis, as above noted (which may be considered as peculiar to the human 
species), the manner in which the joints yield is probably very similar to 
what obtains in the case of the cow. The sacrum acts in this case as a 
wedge separating the ossa innominata and causing the symphysis to open 




Diagram showing the oscillatory movement 
referred to. (Matthews Dunt an.) 



1 Matthews Duncan. Op. Cit., p. 142. 



THE PELVIS. 33 

with a hinge motion, while, during the violent efforts of labor, the whole 
sacrum may probably be driven backwards to a trifling extent. Sepa- 
ration of the bones at the symphysis is occasionally observed, but this is 
probably the exception, while the other is the rule. The development of 
the synovial membranes seems, when taken along with the above facts, 
to warrant the conclusion arrived at by Lenoir, " that the articulations 
of the pelvis proper should not be considered as amphiarthroses, but as 

The word " Midwifery," it is proper here to state, is employed in this 
work in the more extended sense in which it is used by Rigby and other 
English authors, and not in the limited sense which is implied by the 
French accouchement^ and the German Greburtshulfe. It signifies, 
therefore, that Science and Art, which has for its object the management 
of woman and her offspring during Pregnansy, Labor, and the Puerperal 
State. 



CHAPTEE II. 

THE PELVIS. 

Os Innominatum : Sao'um: Coccyx. — The Pelvis as a Whole: '■'■ Irue''^ and 
^^ False." — Difference between Male and Female Pel cis : at Brim; in Cavitij ; 
and at Outlet. — Pelcic Articulations : (a) Pelvi-LumJ)ar ; (h) Sacro-Coccygeal ; 
(c) Sacro-Illac ; (d) Symjjhysis Puhis ; (e) Obturator Ligaments ; (f) Sacro- 
Sciatic Ligaments. — Inclination of Pelvis. — Axis of the True Pelvis. — Brim or 
Inlet. — Cavity. — Outlet. — Pelvic Diameters. — Pelvic Angles. — Development of 
Pelvis. — Certain Soft Parts connected with Pelvis; Obturator Internus and 
Pyriformis Muscles ; " Floor" of Pelvis. 

The Pelvis, as has already been observed, is composed in Man, as in 
almost all the other Mammalia, of three parts: 1st, an os innoininatum, 
formed by the union of three principal pieces, the ilium., ischium^ and 
jntbis, and some other epiphysial parts, the complete fusion of which into 
one mass is only complete about the twentieth year; 2d, the saci^uin ; 
and 3d, the coccyx. 

The Os Innominatum on its external surface exhibits the remarkable 
expansion of the ilium which constitutes one of the distinguishing fea- 
tures of the human race. This large surface serves to give attachment 
to the powerful glutei muscles. Its superior margin is called the crest 
of the ilium ; the projections at I and 2 the anterior, and those at 3 and 
4 the posterior spinous processes. The acetabulum, a deep cavity for 
the reception of the thigh bone, also called the cotyloid cavity, with its 
synovial depression and pit for the reception of the round ligament, is 
shown in the centre of the figure: 5 marks the pectineal or ilio-pectineal 



34 



THE PELVIS 



eminence, a point of some importance in midwifery; and the other parts 
indicated are, 6, the symphysis pubis ; 7, the tuberosity of the ischium; 

8, the thyroid or obturator foramen ; and 

9, the spine of the ischium, which divides 
the great posterior gap into the greater 
and lesser sciatic notches. 

In the view of the internal surface of 
the innominate bone, the figures i to 9 
indicate the same parts as in the pre- 
ceding cut ; lo is the iliac fossa ; 1 1, the 
ilio-pectineal line or brim of the true pel- 




vis; 12, auricular cartilaginous surface 



of the sacro-iliac joint ; 13, rough tuber- 
culated surface for the posterior sacro- 
iliac ligaments; 14., spinous process of 
the pubis, terminating the crest of the 
pubis and the ilio-pectineal line. The 
relative position of the rami of the ischium 
and pubis ; and other points familiar to 
the anatomist, are clearly shown in both 
figures. 

The Sacrum is an irregular wedge- 
shaped or triangular bone, formed by the 
fusion of five vertebrae, and is more or less curved with the concavity 
forwards, the base of the triangle being upwards. It is placed below the 
last lumbar vertebra, above the coccyx, and between the ossa innomi- 
nata, and forms the upper and back part of the pelvis. It is in man 



External surface of right Os Innomi 
natum . 




Fig. 7. 



Internal surface of Os Innoininatum. 




Sacrum and Coccyx — Anterior surface. 



stronger, and relatively larger, than in any other animal, this charac- 
teristTc being specially marked in the female. The external or posterior 
surface is convex and rough, and there are four, and sometimes five, pro- 
cesses placed below each other in the median line, representing the 



BONES OF PELVIS. 85 

spines of the original vertebrae. On either side, four foramina are ob- 
served, through which the posterior sacral nerves pass from the cauda 
equina^ which is contained in a longitudinal canal, the continuation of 
that of the vertebral column. Below the last spinous process, is a tri- 
angular opening, which is the termination of the vertebral canal, and of 
Avhich the lateral margins terminate in a pair of tubercles. These, which 
project downwards and articulate with the cornua of the coccyx, are 
known as the sacral cornua. A row of tubercles is seen on the inside, 
and another on the outside of the foramina — corresponding to the articu- 
lating and transverse processes of the vertebrae. 

The pelvic or anterior surface (Fig. 7) is concave from above down- 
wards, and slightly so from side to side, and is much smoother than the 
posterior. Four foramina, larger than those above described, are pro- 
vided for the transit of the anterior sacral nerves ; and between the fora- 
mina are four ridges, indicating the boundaries of the original vertebral 
constituents of the bone. 

Laterally, there is presented anteriorly an uneven surface of consider- 
able size, covered in the recent state with cartilage, and corresponding 
to the iliac articulating surface shown at 12, Fig. 6. This is called from 
its shape the auricular surface ; and behind it there is an extremely 
rough and uneven surface for the attachment of the posterior sacro-iliac 
ligaments. Below and behind this, the irregular surface gives attach- 
ment to the sacro-sciatic ligaments. 

The oval surface of the sacrum, which, looking upwards and forwards, 
represents the base of the bone, is articulated, through the medium of 
the inter-articular disk, with the last lumbar vertebra ; while its narrow 
inferior extremity, transversely oval, is jointed with the superior surface 
of the Coccyx. 

The Co'^cyx^ the rudiment of the caudal vertebras, generally consists 
of four small vertebral pieces tapering downwards to a point. It derives 
its name from a fancied resemblance to a cuckoo's beak, and is placed 
so as to continue, anteriorly and posteriorly, the curve of the sacrum. 
An oval surface (covered with cartilage and furnished with a synovial 
membrane) articulates with the apex of the sacrum ; and this union is 
strengthened by two small processes which project upwards to meet the 
cornua of the sacrum. Not only is the sacro-coccygeal joint a perfect 
hinge, but the various bones of which the coccyx is composed also admit 
of some motion in early life the one upon the other. In adult life these 
bones are generally anchylosed, and the sacro-coccygeal joint is, in males 
generally, and in females occasionally, lost, so that the sacrum and coccyx 
are firmly joined together. 

The superior mobility of the coccyx in women is universally admitted 
as an im.portant mechanical advantage in the process of parturition, the 
antero-posterior diameter of the outlet being in this w^ay increased, under 
ordinary circumstances, by an inch or even more. Usually, during the 
child-bearing period, the parts are in the condition of complete mobility 
as regards the sacro-coccygeal joint, and yielding also between the first 
and second bone of the coccyx, Avhile the last three bones are united.^ 

' Cazeaux asserts that the sacro-coccjgeal articulation ossifies generally hefore the 
first and second bones become united. If this is correct, the mobility in these cases 
must manifestly be impaired. 



36 THE PELVIS. 

In this respect, however, great irregularities exist, and sometimes, even 
in women who are still young, complete anchylosis is observed. The 
result of this is, of course, a very considerable impediment to delivery, 
and cases are recorded where, during the use of instruments, or even in 
the course of ordinary labor, a fracture of the bones thus anchylosed has 
occurred. Premature fusion of this articulation and malformation of the 
coccyx are conditions by no means very uncommon. The usual form 
assumed in the latter case is projection forwards, encroaching upon the 
conjugate diameter of the outlet ; bat a projection of the coccyx back- 
wards has also been noticed by the writer and others, a condition which 
is interesting as an anatomical peculiarity, but is rather favorable than 
obstructive to the course of natural labor. In cases of fracture, care 
must be taken, during the reparative process, to prevent union in such a 
position as to constitute a possible impediment to delivery in subsequent 
labors. 

The Pelvis as a Whole. — The Pelvis is thus formed by the union of 
several pieces, the articulations or points of junction being, in front, the 
symphysis pubis, and, behind, the sacro-iliac and sacro-coccygeal joints. 
These articulations are greatly strengthened by certain ligamentous 
structures which will be presently described. 

It is divided into two parts by a line, the various parts of which are 
in man alone on the same plane. This, known as the ilio-pectineal line, 
marking the hrim or inlet of the pelvis, runs on each side from the sym- 
physis pubis outwards, upwards, and inwards, forming an irregularly 
oval constriction of the osseous canal. Various points in the course of 
this line, which divides the superior or false from the inferior or true 
pelvis, are of special interest to the obstetrician. In the middle line 
anteriorly is the symphysis pubis. Diverging right and left from this 
point, are the pubic crests, terminating in the pubic spines. The finger, 
on being passed around, next touches the pectineal or ilio-pectineal emi- 
nence, then the ilio-sacral articulation, and finally the projection known 
as the promontory of the sacrum. This last point is of paramount im- 
portance, as the degree of projection which forms the promontory exer- 
cises a most important influence during labor. 

The true pelvis, then, includes the whole of that part of the structure 
which is below the brim as far as the outlet, the space comprised be- 
tween the two being the cavity. Each of these parts requires careful 
and separate consideration ; but, before passing to this part of the sub- 
ject, it is advisable that the striking contrast between the male and female 
pelvis, having an obvious relation to the function of parturition, should 
be noticed. 

The female differs from the male pelvis, in the first place, by the com- 
parative slenderness of the bones, as is well seen in the rami of the 
ischium and pubis, and also by the greater smoothness of the surfaces to 
which muscles are attached. The chief points of distinction, as viewed 
from before, are well shown in Figs. 8 and 9, in both of which the num- 
bers I and 2 represent the extremities of the widest transverse diameter 
of the upper or false pelvis ; 3 and 4 are the acetabula, right and left ; 
S, S^ ^1^® thyroid or obturator foramina; and 6, the sub-pubic angle or 



MALE AND FEMALE PELVES CONTRASTED. 



37 



arch. The differences exhibited are those which exist between 
nary male and female pelvis in middle asre ; in neither 
anything 



an ordi- 
^ m miaaie asre ; m neitner case is there 

exaggerated 
or unusual. The great- 
er distance in Fig. 9 
between the acetabula, 
the wider and shallower 
true pelvis, the trian- 
gular form of the ob- 
turator foramen, the 
greater width between 
the tuberosities of the 
ischia, and the greater 
span of the sub-pubic 
arch, are the chief 
points which at a glance 
show it to be a female 
pelvis. The last-men- 
tioned point of distinc- 
tion is very charac- 
teristic in well-formed 
pelves, the angle in 
males being no more 
than 75° to 80°, while 
in the female it reaches 
from 90° to 100°. 

Viewed from above 
and in front, in the 
axis of the brim, the 
contrast is scarcely less 
marked. In the lower 
of the two figures show- 
ing this view, the fur- 
ther peculiarities of the 

female pelvis are evidenced by the greater expansion of the ilia, 
minor degree of projection of the promontory of the sacrum, and 




Male and Female Pelves contrasted, as seea from before. (Quaiu.) 



the 
the 



marked o;eneral increase in the diameters. In the 



the most 



noteworthy feature of the female pelvis is the diminution in the perpen- 
dicular depth, the symphysis being in the male nearly double the depth, 
while the sacrum is shorter as well as broader, and placed so as to offer 
a more ample concavity. It will also be noticed, in looking downwards 
and backwards, as is shown in Figs. 10 and 11, that three projections 
are seen — posteriorly the sacrum and coccyx, and on either side the con- 
verging ischial planes, culminating in the ischial spines. These projec- 
tions, encroaching, as they manifestly do, on certain measurements of 
the lower parts of the pelvis, have, as will be explained afterwards, a 
yery important bearing upon the mechanical laws which govern the pro- 
cess of parturition. 

If, again, we look at the bony outlet, we find here also three projec- 
tions, posteriorly the sacrum and coccyx, and at the sides the ischial 



38 



THE PELVIS. 



Fis. 10. 




tuberosities. Between the latter is the sub-pubic angle, while between 
them and the sacrum on each side is the irregular sacro-sciatic gap, 

partly closed, as we 
shall see presently, by 
powerful ligamentous 
structures, and much 
more spacious in the 
female than in the 
male.^ These, the main 
features, Avhich enable 
us to distinguish be- 
tween the male and 
female pelvis, having 
now been noticed, we 
shall advert in future 
to the female pelvis 
alone. 

The ligaments and ar- 
ticulations which bind 
the various parts of the 
pelvis together may 
now be briefly noticed, 
a. P elvi-lumhar ar- 
ticulation. — In addi- 
tion to the interverte- 
bral disk, and the liga- 
ments which are strictly 
analogous to those ex- 
isting between the ver- 
tebrae above, attention 
must here be paid to 
the sacro-vertehral and 



Fig. 11. 




Male and Female Pelves contrasted, as viewed iu the Axis of the 
Brim. (Quain.) 



ilio-lumhar ligaments. 



The former passes, expanding as it descends, obliquely from the tip of 
the transverse process of the last lumbar vertebra, to the depressed latter 
part of the base of the sacrum; the latter horizontally betAveen the tip 
of the transverse process of the last lumbar vertebra and the posterior 
margin of the iliac fossa, where it somewhat expands. 

h. SacrO'Coccygeal articulation. — An anterior and posterior ligament, 
and an intervertebral disk, are here found as in the more perfect verte- 
brse. There is observed besides in Avomen, and in a lesser degree in the 
male sex, a synovial membrane, which converts this into a perfect hinge 
joint, the structure and mobility of which become, as has already been 
mentioned, much more obvious in the latter stage of pregnancy. 



1 The greater expansion of the ilia, and divergence of the cotyloid cavities, give 
the chief peculiarities to the female figure, in regard to which the ancient Greek 
sculptors are probably not far from the truth in representing their ideal of female 
beauty as measuring a third more across the hips than the shoulders, while these 
measurements are reversed in tlie case of Apollo. The same peculiarity occasions the 
peculiar swinging gait, which is the more marked in a woman the broader the pelvis 
is in proportion to her height. 



PELVIC ARTICULATIONS. 39 

c. Sacro-iliac articulation, — The bones are here joined by a twofold 
union; in the first place, by the cartilaginous auricular surfaces which 
are seen anteriorly when the parts are forced asunder, and from which 
the name synchondrosis is often given to the joint. Generally, these 
surfaces are closely united; but in pregnancy, and, probably, under 
certain other circumstances, an indistinct synovial cavity may be demon- 
strated, admitting, as there is every reason to believe, of a certain 
amount of motion. This union is greatly strengthened by the posterior 
sacro-iliac ligaments, consisting of strong irregular bands of fibres which 
pass from the overhanging portion of the ilium to the contiguous rugged 
projections on the lateral surface of the sacrum. One of these bands, 
extending downwards from the posterior superior iliac spine to the third 
or fourth piece of the sacrum, in a direction different from the other 
fibres, is known under the name of the oblique sacro-iliac ligament. An 
anterior sacro-iliac ligament is also described, but is of little anatomical 
importance. 

d. The Si/mphysis Pubis. — This joint is, like the previous one, also 
effected by fibro-cartilaginous plates and ligaments. The two cartilages 
are thicker in front where they come into contact with each other, and 
thinner posteriorly, so as to leave a space which is, as in the other joints 
just described, lined by a synovial membrane. During pregnancy, an 
effect is produced upon this joint precisely similar to what has been 
stated to occur in the sacro-iliac joints, but it is in this case even more 
marked. The articulation is materially strengthened by the ligaments 
which surround it, named respectively posterior, superior, anterior, and 
inferior pubic ligaments. Of these, the posterior is a layer of fibres of 
little strength ; the superior is connected with a band of fibres which 
arises from the spine of the pubis, and conceals the irregularities of the 
crest of the same bone ; the anterior is a layer of irregular fibres passing 
across from one side to the other, and* crossing obliquely the correspond- 
ing fibres from the other side, and the inferior, triangular, or sub-pubic 
ligament is so thick, and so disposed by its attachments to the rami of 
the pubic bones as to give smoothness and roundness to the sub-pubic 
angle, and thereby to facilitate the passage of the foetus. 

e. The obturator ligaments. — These structures, which are more cor- 
rectly described as membranes, close almost entirely the obturator fora- 
mina, giving attachment externally and internally to the obturator muscles, 
and leaving only a small aperture in their upper and outer part, which 
serves to transmit the obturator vessels and nerve. 

/. Sacro-sciatic ligaments. — These are two in number, longer in the 
female than in the male, and become, to some extent, relaxed during 
labor. The posterior^ or great sacro-sciatic ligament (Fig. 12, i), 
which is placed in the inferior and posterior jmrt of the pelvis, is broad 
and triangular in shape, and extends from the inner surface of the ischial 
tuberosity, which is the apex of the triangle, to the side of the coccyx 
and sacrum, as far as the posterior inferior spine of the ilium. This ex- 
tensive attachment constitutes the base. The fibres of the apex expand, 
so as to send a falciform process upwards and forwards, along the margin 
of the ischial ramus, to join the fibres of the obturator fascia; 2 is the 
anterior or small sacro-sciatic ligament, which is both shorter and thinner 



40 



THE PELVIS. 



Fig. 12. 




than the other, and is also of a somewhat triangular shape, its fibres are 
directed forwards and outwards; the fibres constituting its base are 
blended with those of the larger ligament ; and its apex is attached to 

the spine of the ischium. By means of 
these structures, which are ossified in 
some of the lower animals, it will be 
observed that the sacro-sciatic notches 
are converted into foramina, great and 
small sacro- sciatic ; 3 and 4. Through 
the former of these, the pyriform mus- 
cle, the great sciatic nerve, and the 
ischiatic vessels and nerves pass, while 
the latter admits of the exit from the 
pelvis of the obturator internus muscle 
and the pudic vessels and nerve. 

The obstetrician may look upon these 
ligaments as discharging a double func- 
tion. They act, as has already been 
mentioned, by preventing the displace- 
ment of the apex of the sacrum upwards 
and backwards — an accident which, 
without their aid, the very oblique po- 
sition of that bone would in the erect 
posture be likely to engender; and 
therefore, in this sense, they strengthen 
the sacro-iliac articulation. But, in 
addition to this, they partly close the large irregular opening which con- 
stitutes the outlet of the pelvis ; forming, at the same time, the frame- 
work of those soft structures which constitute the floor of the pelvis — 
which exercise a very important influence on the progress of labor, and 
which act also by affording an efficient and elastic support to organs 
which would otherwise be liable to frequent displacement downwards. 

In addition to the ligaments above described, there are others, some 
of them — as those of the hip-joint — of great importance ; but as they 
have no special obstetrical interest, their description may here well be 
omitted. 

Inclination of the Pelvis. — If we place the articulated pelvis on a 
table, so as to bring the tip of the coccyx and the ischial tuberosities into 
the same horizontal plane, the brim of the pelvis will be found to look 
upwards and slightly forwards. This was at one time supposed to be the 
actual position in the erect posture ; and many persons now living may 
remember to have seen articulated skeletons in which the pelvis was so 
placed. Hence the term " horizontal," which use and wont has attached 
to the upper of the two rami of the pubis. Naegele was the first clearly 
to show, not only that this was an error, but that it was a very gross 
one, and that the pelvis was, in the normal position, inclined forwards, to 
such an extent that the plane of the brim met the horizon at an angle of 
60° or more (Fig. 13, a). The same observer, after examining a large 
number of well-formed female bodies, concluded, further, that the average 
height of the promontory of the sacrum above the upper margin of the 



Internal surface of Female Pelvis, show- 
ing — 1, 2, greater and lesser Sacro-Sciatic 
Ligaments ; 3, 4, greater and lesser Gaps or 
Foramina. 



AXIS OF THE PELVIS. 



41 



symphysis pubis is about 3f inches, and that a line drawn from the tip 
of the coccyx to the lowest part of the symphysis, formed with the horizon 
at h an angle which varies greatly, but which may be stated, as an ave- 
rage, at about 11°. In reference to this, however, it must be borne in 
mind, that the recession of the coccyx implies a movement downwards, as 
well as backwards, and that, consequently, this angle will be rendered 
still more acute during the 
passage of the child. The 
axis of the brim of the pelvis, 
then, is a line, (?, cZ, which 
passes upwards and strongly 
forwards, while that of the 
bony outlet is directed down- 
wards and slightly backwards. 
The axis of the cavity is usually 
described as the perpendicular 
of a line drawn from the mid- 
dle of the symphysis pubis to 
the centre of the sacro-coc- 
cygeal curve. 

Axis of the True Pelvis. 
— If the bony pelvis were a 
simple cylinder, the demon- 
stration of its axis would be 
a very simple matter. All 
that would then be necessary 
would be to make a section, 
perpendicular to its walls, 
when the axis of the cavity 
would be shown to be a line intersecting the plane represented by this 
section, and equidistant from every part of the cylinder wall. The same 
simplicity of description will not, however, suffice in the case of the 
irregular and curved pelvic cylinder. What is known as the '' curve of 
Cams" was at one time generally supposed to represent the axis of the 
pelvis. This curve is described in the following manner : The compasses 
are opened to the extent of 2 J- inches : one point is placed upon the cen- 
tral point of the posterior surface of the symphysis, while with the other 
a curve is drawn from the plane of the brim to the plane of the outlet, 
the segment of the circle thus indicated being assumed to represent the 
axis of the pelvis. A mere superficial observation of the human pelvis 
will serve to show that neither this nor the segment of any circle can 
truly, or even approximately, represent the axis in question. 

Although not absolutely free from technical objection, we may assume 
that the followino; more modern view brino;s us nearer the truth : If we 
produce the lines in the above diagram, which represent the planes of the 
brim and outlet, to their point of intersection in front of the symphysis 
at 0, and from this common centre draw an infinite number of radii pass- 
ing through the pelvic cavity, each of these radii may be held to represent 




Diagram showing the iBclination and Axis of the 
True Pelvis. 



• " Das weibliche Beckeii," etc. Carlsrulie. 1825. 



42 



THE PELVIS. 



Fig. 14. 



the plane of that portion of the cavity through which it passes. If we 
then draw a line which shall pass through the geometrical centre of each 
of these planes, that line will be found to be a curve, which coincides 
very closely with the axis of the true pelvis, which is the segment of no 
circle, and which has been described as an irregular parabola. One 
point must here, however, be noted — that as the terminal planes or radii 

will be modified by the motion of the 
coccyx during labor, so in like manner 
will the inferior portion of the curve be 
proportionally altered . This is indicated 
in Fig. 13, where the line c f marks the 
parabolic curve or assumed true pelvic 
axis. 

We must here be careful in drawing 
a distinction between the axis of the 
outlet of the bony pelvis, and that axis 
which represents the direction in which 
the child is born. In considering the 
latter, it is essential that the soft parts 
forming the floor of the pelvis should be 
looked upon as constituting the posterior 
and inferior boundary of a continuation 
of the pelvic canal. These parts, which 
extend from the tip of the coccyx to the 
posterior commissure of the vagina, are 
subjected during delivery to an amount 
of stretching for which nature makes 
due provision. The margins of the 
anus are dragged apart, the perineum 
distends in all directions in a manner 
apparently incompatible with the integ- 
rity of that structure, until ultimately, 
at the moment of expulsion, the four- 
chette is driven downwards and carried 
forwards to such an extent, that a line 
drawn from the subpubic angle to the 
edge of the distended perineum, shows the plane of the outlet of the 
completed pelvic canal to look, not downwards, but almost directly for- 
wards (Fig. 14, a 6). The line ^, perpendicular to, and meeting the 
centre of this plane, is then the axis of expulsion. The tendency of 
that part of the child which is first born is to move upwards and forwards 
under the pubic arch, and in front of the symphysis, in continuation of 
the curve indicated in the diagram by dotted lines. 

Let us now look more closely at the various parts of this tube which 
attract special notice — viz., the Brim, the Cavity, and the Outlet. The 
Brim presents (Fig. 11, p. 38) an irregular oval appearance, the long 
diameter of the oval being from side to side. It has been found on an 
average to measure in the antero-posterior or conjugate diameter, a p, 
which is taken from the promontory of the sacrum to the upper edge of 
the symphysis pubis, 4J inches. Its greatest transverse measurement, 




Diagram showing the Axis of the 
Parcurieat Caual. 



INTERIOR OF PELVIS, 



43 



Fig. 15. 



t f, is 5J inches. In addition to these, there is also described an ohlique 
diameter, extending from the sacro-iliac synchondrosis on either side to 
a point near the ilio-pectineal eminence on the other. This measures 5 
inches, and it must be remembered that these diameters take their name 
" right oblique''^ (r o), or " left oblique''^ (I o')^accordi7ig to the sacro-iliac 
synchondrosis from luhich they spring} 

It will thus be obsers^ed that, in the skeleton, the transverse is the 
longest diameter of the three, but, when the soft parts are in situ, this is 
not the case, as the iliacus muscle overlaps the brim, so as to diminish 
the transverse while it scarcely encroaches upon the oblique diameter. 
The eifect of this is that the oblique is practiced! y the longest diameter. 
a fact which we find of great interest and importance when we study the 
relation of the diameters to the foetal head. 

The Cavity of the pelvis is the whole tube between the brim and the 
outlet. As a general rule, the deeper the cavity the more difficult is the 
labor, for in this case the pelvis approximates in its conformation to the 
male type. If the diameters are proportionally enlarged, labor may be, 
it is true, quite easy ; but the rule un- 
doubtedly is that, in the case of the 
tall handsome woman with dignified 
gait and carriage, the probability of a 
difficult labor is much greater than in 
the short, wide-hipped woman, in whom 
the swinging, or (to put it less gal- 
lantly) the waddling motion of her sex 
is more obvious. The cavity, as a 
single glance will show (Fig. 15), is 
deep posteriorly and shallow anteriorly. 
The average depth of the symphysis 
pubis gives the anterior depth at IJ 
inches. The height of the planes of 
the ischia Avhich corresponds to the 
middle depth may be stated as about 
3J inches. The depth posteriorly may 
be set down, if we measure directly 
from the promontory of the sacrum to 
the tip of the coccyx, as -ij inches, and, 
if we follow the curve of the sacrum, it 
Avill be increased to about 5J inches, 
the former of these measurements making no allowance, however, for 
the yielding of the coccyx. Three diameters are also taken in the case 
of the cavity : the conjugate^ from the centre of the symphysis pubis to 
the upper margin of the third sacral vertebra, b\ inches ; the transverse, 
from a point corresponding to the lower margin of the acetabulum on one 
side to the corresponding point on the other, 5 inches ; and the oblique, 




Interior of Pelvis, showing the Ischial 
Plaues. 



1 In regard to tliis there unfortuiiatelr exists some confusion. The diameters are 
named right and left, as in the text, by the best English and German ^vriters, but some 
eminent French and American authors use the same words with reference to the coty- 
loid cavity in the neighborhood of which each diameter terminates — thus inverting 
the meaning of the terms. 



44 



THE PELVIS 



from the centre of the great sacro-sciatic foramen on one side to the centre 
of the obturator membrane on the other, 5 J inches. 

Looking now at the internal surface of the pelvic canal in a section 
such as is here shown, we may observe that the lateral wall is divided 
into two parts bv a not very obvious line of demarcation (a 6) leading 
downwards and backwards, from the ilio-pectineal eminence to the spine 
of the ischium. That part of the ischium which is in front of this looks 
slightly forwards, that which is behind slightly backwards. These are 
the anterior and posterior inclined planes of the ischium, supposed by 
Desormeaux, Tyler Smith, and many others, to determine the rotation 
of the head in the mechanism of parturition. To this, however, we shall 
return. 

While the brim or inlet of the pelvis is directed, as w^e have seen, up- 
wards and forwards in the erect posture, the outlet, owing to the curve 
formed by the axis of the cavity, looks backwards, and, when the coccyx 
is extended, almost directly downwards. 

The conjugate diameter of the outlet (Fig. 16) extends from the lower 

margin of the symphysis pubis 
Fig. 16. to the tip of the coccyx, and 

may be set down as 5 inches. 
In many cases the measure- 
ment is much less than this, 
and in any case the diameter 
may be increased to the ex- 
tent of an inch or even more 
by the mobility of the coccyx 
during labor. The transverse 
diameter, from one tuber ischii 
to the other, is about 4f inches ; 
and the oblique, from the mid- 
dle of the lower edge of the 
great sacro-sciatic ligament 
on one side to the point of 
union between the ischium and pubis on the other, also 4f inches. 

The facts which are brought out by those figures are chiefly these : 
(«) that the transverse measurement of the pelvic tube becomes pro- 
gressively diminished from above downwards, being greatest at the brim 
and smallest at the outlet: this is due, as a single glance downwards in 
the axis of the brim will show (Fig. 11), to the gradual approximation 
of the ischia: (b) that the conjugate diameter is, on the contrary, in- 
creased from above downwards, in consequence of the recession or curve 
of the sacrum, progressively from brim to outlet, if we allow for the 
bending back of the coccyx. These facts, which are associated w^ith a 
remarkable rotation which the child undergoes during labor, are more 
clearly shown when, as in the following Table, the figures above noted 
are brought into juxtaposition. Along with these, a few of the more 
important of the many measurements which have been made of the female 
pelvis are also set down in inches, according to the average of the most 
recent and approved observations. 




Outlet of the Female Pelvis. 



PELVIC DIAMETERS. 45 



MEASUREMENTS OF THE FEMALE PELVIS. 

1. Circumferential measurement of tlie Brim . . . .17 

2. Between widest i^art of Iliac Crests ..... 10| 

3. " Anterior Superior Spines of Ilium .... lOj 

4. " Front of Symphysis and Sacral Spines ... 7 

5. True Pelyis. Conjugate. Transverse, Oblique. 

Brim 4^ b\ 5 

Cavitu 5^ 5 [5A]i 

Outlet 52 4f [4|] 

All the measurements given in this Table are, it must be remembered, 
those of the skeleton — no allowance being in any case made for the soft 
parts ; and to them we may add another measurement, which has an 
important bearing on practical considerations arising from the study of 
a certain class of pelvic deformities. This is the %acro- cotyloid diameter^ 
which is about SJ inches in a well-formed pelvis, and is represented by 
a line drawn from the centre of the sacral promontory to the ilio-pectineal 
eminence. The encroachment of the psoas and iliacus muscles, with in- 
vesting and other structures, reduces the transverse diameter of the brim 
b}^ about half an inch, while the other diameters of the brim, as well as 
of the cavity and outlet, are only reduced by an eighth to a quarter of 
an inch at the most. The oblique diameters are least of all affected ; 
but, owing to the presence of the rectum on the left side, the left oblique 
diameter is slightly shorter than the right. These facts have to be borne 
in mind in the course of examinations Avhich are made with a view^ of 
estimating the capacity of the pelvis in its various parts — a question often 
of vital import in the practice of midwifery ; and in such investigations 
it is also useful to know that the distance from the lower edge of the 
symphysis to the promontory of the sacrum is about half an inch more 
than the conjugate of the brim. In regard to the measurements num- 
bered 2, 3, and 4, in the table, if these are to be estimated by measure- 
ments in the living body, from two to three inches mast be added for the 
tegumentary and other external structures. 

In addition to the angles which have already been described as formed 
with the horizon by the planes of the brim and outlet, and measuring 
respectively (30° and 11° (Fig. 13), and the sub-pubic angle, there are 
several others which should not be overlooked. Tlie sacr o-vert eh ral angle 
is that which the sacrum fornis with the vertebral column, and is esti- 
mated as 117° in the male, and 130° in the female. The symphysis 
forms with the horizon an angle of 35° to 40° in the erect posture ; 
while the ischium forms with the ilium, or rather w^ith the imaginary line 
leading downwards and forwards, and representing the mean direction of 
that bone, an angle of 110° to 115°. This latter is called the ilio-ischial 
angle.^ 

Develojjmejit of the Pelvis. — From birth to the age of puberty, the 
pelvis differs in many respects, besides mere size and state of ossification, 

^ The oblique diameters of the cavity and outlet are placed in brackets, as, not 
being taken from fixed bony points, they are of comparatively little importance. 

2 Six inches wlien coccyx forced back. 

3 For a complete and exhaustive demonstration of these and other points alluded 
to, see Mr. Wood's Essay; Art. " Pelvis," in Todd's Cyclopaedia. 



46 THE PELVIS. 

from the same part in the adult. At birth, the iliac fossae are flat, and 
have their surfaces directed more forwards. The symphysis is short. 
The sacrum is very narrow, and on this account the transverse measure- 
ments are relatively smaller than the conjugate ; while all the diameters 
are extremely small, and so insufficient for the reception of what are 
known as pelvic organs, that these parts are for the most part lodged in 
the abdominal cavity. This contributes, no doubt, to the abdominal 
prominence which is so familiar in the newly born. The sacrum is very 
flat, and there is also very little approximation of the inner surfaces of 
the ischium, which gives to the sides of the pelvis a general appearance 
of parallelism not existing in the adult. A very general idea prevails 
among the best modern writers that the inclination of the brim is con- 
siderably increased as compared with the adult. This has been stated 
by Oruveilbier and Burns, and even more decidedly by Cazeaux. '' The 
sacrum," says the latter, " is so flat and so elevated, that a horizontal 
line drawn from the upper part of the pubis will pass below the coccyx." 
Mr. Wood, however, has given the weight of his authority in favor of 
another view, and states it as the result of his careful observations, made 
by sections when the soft parts Avere in situ, that he has always found 
the tip of the coccyx '' as low" as the lowe?' border of the symphysis 
pubis." Such a serious discrepancy can only be accounted for by sup- 
posing that a different mode of observation has been adopted. 

The child, it must be remembered, is not as yet structurally fit for the 
erect position, and therefore maintains for many months after birth a 
posture similar to that which it assumed in the womb, 
with the thighs flexed upon the abdomen, and the sym- 
physis tilted upwards. To measure the pelvic angles of 
the child, with the view of comparing them with those of 
the adult, it is essential that the child should be placed 
in such a position as may, without violence or rupture of 
tissue, coincide as nearly as possible with the erect pos- 
ture, and if this be done the pelvis will usually be found 
to present the appearance shown in Fig. 17. From this 
point of view Cazeaux is possibly correct ; but if a sec- 
tion be made through a child in the position which it 
instinctively adopts, the relative position of parts, as described and figured 
by Mr. Wood, will probably under these circumstances be confirmed. 
The other distinctive characteristics of the infant pelvis are also shown 
in the figure, in which, moreover, the general resemblance to the type of 
the Simiadse may afford some pleasing suggestions to the disciples of 
Darwin. 

According to Burns, it is not until the tenth year that the transverse 
comes to exceed the conjugate measurement. There is, however, nothing 
which would enable us to distinguish with even an approach to certainty 
between the male and female pelvis until the period of puberty approaches, 
when nature, availing herself of the plastic nature of these bones, due 
to their tardy ossification, moulds the parts, in full view of the important 
physiological function which is about to be instituted, so that the marked 
characteristic features of the female pelvis are now rapidly developed. 




FLOOR OF THE PELVIS. 47 

Hitherto we have looked at the pelvis as an osseous and ligamentous 
structure. Connected in the most intimate manner with it, however, there 
are certain soft structures which cannot properly be included in a descrip- 
tion of the organs of generation, and which fall therefore to be considered 
in this place. The fan-shaped iliacas muscle forms, along with the psoas 
on each side, a sort of cushion, which, besides giving proper support to 
other viscera, forms a rest for the gravid uterus, and an effectual pro- 
tection for it against shock. It encroaches, as we have seen, upon the 
transverse, without materially lessening the oblique diameter, and this 
encroachment is more marked when the muscles are in a state of con- 
traction. On each side of the cavity, there are two muscles covering in 
to a great extent the great sciatic and obturator gaps. These are the 
pyrifo7nnis and obturator internus muscles, to the contraction of which 
the rotation of the foetal head which takes place within the cavity was 
supposed by Flamand of Strassburg to be due. The dimensions of the 
cavity are further reduced by the rectum and bladder, and by the cellu- 
lar tissue which, when overcharged with fat, may form a barrier to the 
progress of labor, rendering its course more tedious. 

The perineal strait, open in the skeleton, is occupied by firm contrac- 
tile tissues, which form a floor for the support of the pelvic, and, indi- 
rectly, of the abdominal viscera. This floor consists of two muscular 
layers. Of these, the internal layer, formed by the levator am and coc- 
cygeus, has its concavity directed upwards, and has been named, not in- 
appropriately, by Meyer the "pelvic diaphragm." The external layer, 
with its concavity doAvnwards, is formed of the muscles of the perineum, 
known to anatomists as the sphincter ani transversus j^ei^inei ischio-caver- 
oiosus, and sphincter vagince. The pudic vessels and nerves, cellular 
tissue, the pelvic aponeurosis, an inter-muscular aponeurosis, and the 
skin, complete this floor, which at the time of delivery becomes thin and 
distended to a very considerable extent. In the ordinary state, the 
measurement from the coccyx to the posterior commissure of the vulva 
is a little more than three inches ; but, during labor, the distension is such 
that it is increased to 5, 6, 6J inches, or even more, by the stretching of 
the parts, and by overcoming the tonic contraction of the sphincter. 



48 FEMALE ORGANS OF GENERATION 



CHAPTEE III. 

FEMALE OKGANS OF GENERATION. 

A. External. Labia; Perineum ; Hymen^ etc. — Erectile Tissue — The Vagina. — 

Glands of the External Organs — Abnormal Conditions. — Mammary Glands. 

B. Internal. Ihe Uterus ; Situation of; Divided into Body and Cervix; Axis of 

Unimpregnated Uterus ; Cavity of ; Fundus; Surf aces and Borders ; Serous 
Covering of ; Broad Ligaments ; Round Ligaments ; Vesica- Uterine Folds. — 
The Fallopian Tubes — Parovarium — Folds of Douglas. — Equilibrium of the 
Uterus. 

The Organs of Generation in the female include — besides the Uterus, 
Ovaries, and other parts situated internally — the Vagina, Vulva, and 
Mons Veneris. These latter being, more . properly, external organs, 
anatomists have divided the whole into External and Internal Organs. 

External Organs of Generation. — Immediately over the symphysis 
pubis, above and in front of the opening of the vulva or pudendum, is 
a firm cushion-like eminence, about two inches in depth and three inches 
transversely. This, which is called the 3fons Veneris., varies in promi- 
nence according to the conformation of the pubes, and the amount of 
adipose and cellular tissue in it and the contiguous parts. After puberty, 
it is covered with hair, and is abundantly furnished with sebaceous fol- 
licles, which were supposed by Moreau to contribute in some measure to 
the dilatation of the external parts at the moment of delivery. Con- 
tinuous with this structure, extending downwards and backwards, and 
becoming gradually thinner in their course, are two rounded folds of 
integument, which, diverging from each other, leave in the median line 
an elliptical interval between them. These are the labia^ maj'ora, labia 
externa, or labia pudendi. They present an external surface, covered 
with skin similar to that of the mons veneris, and an internal surface 
lined with mucous membrane, which is the commencement of the genito- 
urinary tract. Behind, the thinner margins unite, forming the posterior 
commissure of the vagina. The foicrchette, or fra^nidum pudendi, is a 
transverse fold in front of this, which resembles and has been aptly com- 
pared to the continuation of the skin at the roots of the fingers, and is 
very generally torn in first labors. The depression between the fourchette 
and the commissure is named the fossa navicularis. Between the skin 
and superficial fascia of the labia there exists a purse-shaped sac, which 
has been described by M. Broca as analogous to the dartos tunic of the 
scrotum. This sac is filled with fat and cellular tissue, is the receptacle 
occasionally of hernia, and to it have been traced the terminal fibres of 
the round ligament of the uterus. 

The perineum extends from the posterior commissure to the anus, and 
is usually about an inch and a half in length. It is made up of highly 



THE HYMEN. 49 

distensible cellular tissue, and has been said to contain some yellow elastic 
tissue. It is, undoubtedly, susceptible of great distension during labor, 
without, under ordinary circumstances, any risk of rupture. 

On separating the labia majora, the labia minora or nymphce are 
brought into view. These are two thick mucous folds, somewhat resem- 
bling the comb of a cock, about an inch and a half in length, having their 
origin on the inner surface of the labia majora, and becoming wider as 
they pass upwards and forwards, converging towards the clitoris, with 
the prepuce of which they are continuous. The clitoris is a small erec- 
tile tubercle, situated somewhat above the level of the lower margin of 
the symphysis pubis. Like the penis of the male, it has a suspensory 
ligament, two crura, two corpora cavernosa, and a glans, but has no 
corpus spongiosum nor urethra. Two muscles, corresponding to the 
ischio-cavernosus, are in the female called "erectores clitoridis." The 
vestibule is a small triangular space, bounded above by the clitoris, below 
by the urethra, and on either side by the diverging nymphge. It is about 
an inch in length, is smooth on the surface, and is specially important as 
a guide to the fino;er of the accoucheur in the introduction of the catheter 
— an operation which should always be performed, if possible, without 
exposing the patient. The meatus urinarius is indicated by a small pro- 
jection, easily discovered by the finger, immediately beneath the vestibule, 
and in front of the vaginal entrance. The catheter being laid along the 
palmar surface of the forefinger, its point is guided towards the projection 
just mentioned, when, if the other extremity is gently depressed, it will 
usually pass in without the slightest difficulty. When the parts are dis- 
torted by disease, or by the tumefaction which occurs after labor, it is 
often necessary to expose the patient before the instrument can be intro- 
duced. The urethra is about one inch to one inch and a half in length, 
highly distensible, and, in the unimpregnated state, almost straight. In 
young children, what may be called the urinary parts of the vulva are 
prominent, and it is not till the approach of puberty, that the <;/3nital 
portion is observed to predominate. 

Behind and beneath the meatus, is the orifice of the Vagina, varying 
greatly in appearance and in dimension in young girls, in those who are 
no longer virgins, and in those who have borne children. In virgins, it 
is generally closed to a considerable extent by a thin fold of the mucous 
membrane called the hymeii^ which was at one time supposed to be the 
" seal of virginity," but which may be ruptured by many causes other 
than coitus. Its usual form is crescentic, with the concavity upwards, 
closing in the posterior, and, to some extent, the lateral portions of the 
opening ; but it may present itself under various other forms. It has 
been frequently observed, for example, to be circular, with a small per- 
foration in the centre ; or cribi;iform, with several perforations, as in a 
medico-legal case which the writer was called upon to examine ; or infun- 
dibuliform, or offering rarer peculiarities. In some instances, the closure 
is complete. But, whether complete or partial, or under whatsoever 
form it may present itself, the first effects of coitus are generally suffi- 
cient to rupture this fragile partition. In rare cases, however, its texture 
is so firm and resistant, that penetration is rendered impossible until the 
structure has been divided by the scalpel ; and in cases of complete do- 
4 



50 



FEMALE ORaANS OF GENERATION 



sure, where there is no question of coition, the operation may be neces- 
sitated from its being a barrier to the menstrual flow. 

When the hymen is absent, small projections, called caru7iculm myrti- 
formes, generally about three or four on each side, are noticed on the 
margins of the opening. These were generally supposed to be the 
remains of the ruptured hymen ; but, as they have been found to exist 
along with the hymen, this must be looked upon as open to doubt. 

Bloodvessels are supplied in abundance to all parts of the external 
generative organs, and in certain situations the masses of venous plexuses 
which are termed erectile tissue are found in considerable quantity. Fig. 
18, from Kobelt, shows these structures carefully dissected. Besides 



Fi^. 18. 




W////;(iii\\\%\vSs\\m^^ 
External Organs, partiaUy dissected. (Kobelt.) 



the erectile parts already mentioned, there are, on either side of the 
vaginal orifice, two large leech-shaped masses, a, called hulhi vestibuU, 
which are about an inch in length, and are connected with the crura of 
the clitoris and the rami of the pubis, covered internally by the mucous 
membrane, and embraced on the outside by the fibres of the constrictor 
vaginae muscle. A small plexus — the jjars intermedia of Kobelt — has 
direct vascular connection with the bulbs. These erectile tissues receive 
their blood from the internal pudic arteries. 

The Vagina (va) is a membranous and highly dilatable tube, which 
serves to connect the vulva with the uterus. It is situated in the true 
pelvis, between the bladder and rectum anteriorly and posteriorly, and 
the levatores ani muscles at the sides. Its axis is a curve, Avhich corre- 
sponds in some degree to that of the pelvis ; and, in consequence, its 
anterior is shorter than its posterior wall, the former being about four, 
and the latter five or six, inches in length. It is narrowest at the vulva, 
where it is embraced by the constrictor vaginae muscle, and widest at its 
middle part, where it is extended transversely, owing to its being com- 
pressed by the organs before and behind. The thickest part of the tube 



THE VAGIXA. 51 

is its anterior wall, where it is intimately connected with the bladder, 
and with the urethra, wliich is, as it were, imbedded in it. Its connec- 
tion with the levatores ani muscles and the rectum is much looser, which 
admits of easy dilatation, and this also accounts for the fact that the 
rectum is rarely dragged down in uterine displacements, while the blad- 
der is, from its closer connection, almost invariably altered in its rela- 
tions. In the upper part of its posterior surface, it is separated from 
the rectum by a double fold of serous membrane, which forms a pouch 
of the peritoneal cavity. 

The external layer of the vagina is composed mainly of dense areolar 
tissue, beneath which there are two indistinct layers of muscular fibres 
of the unstriped variety, the external being disposed longitudinally, 
while the internal are circular in their direction. Around the tube, a 
layer of loose erectile tissue has been found, which is most distinct at 
the lower part. Internally, it is lined throughout by mucous membrane, 
which is covered with epithelium of the squamous variety, and is con- 
tinuous in one direction with the skin and in the other with the mucous 
membrane of the uterus. Along the. anterior and posterior walls, the 
membrane is slightly raised in the middle line, so as to form a ridge 
similar to the raph^ in other parts. These ridges are called columnce 
rugarum ; and, at right angles to them, the membrane is thrown into 
numerous transverse folds (I'ucjce) which are always more distinct in 
those who have not borne children, and which are obviously destined 
to facilitate the dilatation of the parts. 

The upper part of the vagina embraces the neck of the uterus in such 
a manner that the va2;inal mucous membrane is reflected over the neck of 
the uterus some way above its mouth, the point of reflection being higher 
on the posterior wall ; and it has been observed that the connection be- 
tween this membrane and the subjacent uterine tissue is very firm close 
to the mouth of the womb, and is much less so as it approaches the point 
of reflection. This admits of the complete dilatation of the uterus, and 
the consecjuent obliteration of the neck. The other tissues of the vagina 
are continuous, or at least very closely united, with the corresponding 
tissues of the uterus. A reference to Fig. 19 will serve to show that the 
vagina terminates in a cul-de-sac above and behind the uterus, and that 
at this point its wall is for some distance in direct relation with the peri- 
toneal cavity, a fact of no little practical importance. The cul-de-sac of 
peritoneum with which it is in contact is termed the recto-vaginal j^ouch^ 
and sometimes the pouch of Douglas. 

Further, the vagina may be considered as the organ of copulation in 
women ; and as the canal which is destined to transmit the menstrual 
discharge, and, in case of pregnancy, the product of conception. It is 
abundantly supplied with vessels and nerves. The blood supply is de- 
rived from the vaginal and other branches of the internal iliac artery, 
and returns by means of corresponding veins, after forming at each side 
a vaginal plexus. The nerves have been traced to two sources, the hypo- 
gastric plexus of the sympathetic system, and the fourth sacral and pudic 
nerves of the spinal system. 

The external organs of generation are furnished with numerous glands 
of various kinds, which have been very fully described by MM. Robert 



52 



FEMALE ORGANS OF GENERATION. 



and Huguier. The latter divides the glands of the vulva and entrance 
of the vagina into sebaceous and muciparous follicles. The sebaceous 
variety is met with in great abundance over the whole of the parts from 
the geni to-crural folds to the clitoris and nymphae. Those of the nymphae 



Fig. 19. 




Showing the relative position of the Pelvic Organs. 

are exclusively sebaceous, and they all find their function in the secretion 
of an oily fluid, which maintains the elasticity, moisture, and sensibility 
of the parts, prevents them from adhering, and, above all, protects them 
from the irritating action of the urine. The muciparous follicles differ 
essentially in their situation, and in the nature of the fluid which they 
secrete. Although here and there they are isolated, as a general rule 
they are found in groups. One such group of eight or ten follicles is 
found imbedded in the mucous membrane of the vestibule. Another is 
observed in the immediate neighborhood of the meatus urinarius, their 
orifices being extremely minute, and opening for the most part below the 
aperture of the meatus, upon, or close to, the little tubercle already des- 
cribed. A third group is described as external to these, and situated on 
either side of the urethra ; and a fourth, the orifices of which have been 
observed on each side of the vaginal opening, at the root of the hymen or 
carunculse myrtiformes. 

Under the muciparous class, two compound or conglomerate glands 
were long ago described by Bertholin, and more recently by anatomists 
under the name of the vulvo-vaginal glands. They are also called the 



EXTERNAL ORGANS. 53 

glands of Duverney, and are in many respects analogous to Cowper's 
glands in the male. They are about the size of a small bean, variable 
in form, and of a reddish-yellow color. Their development is said to 
proceed, pari "passu, with that of the ovaries, reaching the maximum 
during the child-bearing period, and being comparatively insignificant in 
youth and old age. They are situated one on each side, at the entrance 
of the vagina, beneath the superficial fascia, with their inner surface 
united to the vagina by areolar tissue, and the outer surface in relation 
with the constrictor muscle of the vagina. Each of the lobes of which 
the gland is composed gives origin to a little duct, all of which conduits 
ultimately unite at the internal and upper part, to form a common excre- 
tory duct, which proceeds horizontally forwards as far as the vaginal 
orifice, where it terminates within the nymphse, and external to the hymen 
or carunculae myrtiformes. The orifice is very small and valvular, and 
is often only to be discovered with difficulty ; but its situation is usually 
indicated by an increased vascularity at the point whence it emerges. 
These glands secrete a fluid (resembling that which is found in the pros- 
tate in the male) which is increased in quantity during coition, and is said 
to be expelled in jets, as occasionally occurs with the contents of the sali- 
vary duct. By lubricating the parts it facilitates coition, and by preserving 
their moisture probably tends to maintain their extreme sensibility. 

The appearance and anatomical relations of the external organs of 
generation vary greatly according to age, and in consequence of venereal 
indulgence, or of child-bearing. At birth, the nymphie project beyond 
the level of the labia majora,and the parts in general look more forward 
than in the adult. When puberty approaches, hair appears on the pubes, 
the nymphse disappear between the labia, and the parts look downwards, 
so that in the erect posture nothing can be seen from before except the 
mons veneris ; whereas, in the child, the upper parts of the vulva are 
distinctly visible. The labia are symmetrical, thicker above than below, 
closely applied to each other, and of a fresh rose color on their mucous 
surfaces. Venereal indulgence, and still more, pregnancy and child- 
bearing, modify, in a great measure, the appearance here described. 
The hymen is ruptured, and the carunculie myrtiformes come into view. 
The labia lose their regularit}^, and become of a more dingy hue on their 
mucous surface. The nyraphge are again visible, partly by separation of 
the labia, and partly in consequence of hypertrophy of their tissue, while 
their vivid rose tint becomes replaced by a darker shade of color. In 
some cases the hypertrophy is very remarkable, and when so, is usually 
unequal on the two sides. This is said to be very common among Hot- 
tentot women, where the nymphae often become enormously enlarged. In 
women who have borne children the fourcheite is usually ruptured, and 
the vao:inal orifice remains lar2:e and irresiular. The vagina asiain, which 
in virgins presents the appearances already described, may now^ lose, to 
a great extent, its rugae ; and the deepening of its color is by some sup- 
posed to be a not unimportant sign of pregnancy. In women of advanced 
age, the vagina becomes contracted, being again thrown into folds, and 
greatly diminished in caliber. Its orifice shares in the contraction, the 
nymphse shrink, and the labia majora come once more into proximity, 



54 FEMALE ORGANS OF GENERATION. 

while the glandular, erectile, and other special tissues become atrophied. 
In a word, the characteristics of childhood are again partially restored. 

Abnormal conditions, constituting some form or other of congenital 
malformation, are occasionally met with in the external organs. The 
labia may be imperfect or rudimentary, preserving in this respect the 
foetal condition of the parts ; they may be developed on one side only ; 
or they may present the appearance of several folds. In cases of defi- 
ciency of the lower part of the abdominal wall and of the bladder, along 
with separation of the symphysis pubis, the labia are imperfectly formed 
and set wider apart than usual. The posterior commissure of the vaginal 
orifice may be hypertrophied and pushed forwards so as to cover the 
aperture. The labia are, in some instances, adherent along the median 
line, to such an extent that an opening is left sufficient only for the passage 
of the urine. Induration and hypertrophy such as to constitute elephan- 
tiasis has also, although rarely, been noticed. Entire absence of the 
clitoris, unassociated with any other form of malformation, is very rare. 
It is sometimes so small that it can with difficulty be discovered, and in 
these cases it may be erroneously supposed to be absent ; but it may be 
assumed that, unless other parts, such as the nymphge, are absent, the 
clitoris is only rudimentary. This organ is much more frequently en- 
larged, generally, no doubt, as the result of disease, but sometimes it is 
a pure hypertrophy of the normal tissues, when it may approach the 
dimensions of the penis, and constitute one of the forms of so-called 
hermaphroditism. An extreme development of the nymphae — common, 
as we have seen, in certain races — may occasionally be met with as a 
peculiarity of structure ; and cases are even recorded where they have 
been found increased to two or even three pairs. 

The folds of which the hymen is composed, ordinarily thin and fragile, 
are occasionally developed to such an extent as to prevent sexual con- 
gress ; while, in some cases, it completely closes the mouth of the 
vagina, preventing not only coition and impregnation, but also menstrua- 
tion, and, for the latter reason, if not for the former, rendering an operation 
necessary. Another condition of these parts which may call for opera- 
tive interference, is what has been called vaghiismus, where there exists 
such spasmodic contraction as prevents proper sexual contact, dilatation 
with or without the use of the scalpel being in such cases often found 
necessary. Congenital absence of the vagina is by no means of very 
rare occurrence. In extreme cases, the whole organ is wanting — the 
vulva terminating abruptly at the point where the vagina, in the ordinary 
condition of parts, commences. In others, a portion of the tube exists, 
but ends in a cul-de-sac at some distance from the os uteri ; while, in 
another class, there is a narrow canal, sufficient only for the passage of 
the menstrual fluid. In many of these cases, free incision may be found 
necessary, in order, by giving egress to the menstrual discharge, to relieve 
the serious symptoms which arrest of that important function is apt to 
engender. 

A vertical septum occasionally exists, constituting the phenomenon of 
double vagina, in which, if complete, there is a hymen to each tube. 
More frequently, however, the septum is incomplete — either commencing 
at the vulva and terminating so as to leave the tube single at its upper 



MAMMARY GLANDS. 55 

part, or, conversely, commencing at the upper part and stopping short of 
the mouth of the vagina. In the latter case, we would expect it to be 
associated with double uterus. Transverse membranous septa also exist 
as congenital malformations, but much more frequently as the result of 
inflammatory action, or of the accidents of previous labors. 

Many of the conditions above detailed may give rise to serious impedi- 
ments, either to delivery, to impregnation, or to the proper performance 
of the menstrual function, and, in consequence, delicate, and even dan- 
gerous, operations may, under such circumstances, be required. 

Mammary Glands. — Intimately associated with the function of the 
reproductive system, are the glands, the presence of which serves to 
distinguish the class Mammalia. On this account, several modern 
writers have, with perfect propriety, included these organs in a descrip- 
tion of the external parts of generation. When they are fully developed 
in a woman, they extend from the third to the sixth or seventh rib, and 
from the side of the sternum to the axilla, the left breast being generally 
the larger of the two. The nipple Qmamilla') projects about the level of 
the fourth rib from near the centre of the gland, and is, in the virgin, 
of a rose pink color. It is surrounded by a ring of similar hue Qareohi) 
varying in tint with the complexion of the individual. Ou the surface 
of this, several small tubercular projections are visible, on each of which 
are the orifices of several glands.^ The tissvie of the nipple is very rich 
in bloodvessels, and contains muscular fibres of the non-striated variety 
with a certain amount of erectile tissue, the surface being covered with 
papilla, which are highly sensitive. The turgescence of the nipple, 
which occurs under irritation, is usually attended with a pleasurable 
sensation. 

The bulk of the breasts, and what gives to them their smooth and 
moulded form, is chiefly fat, which, except at the nipple and areola, 
where the gland is contiguous to the surface, lies beneath the skin, and 
dips down into the intervals between the lobes and lobules of which the 
gland is composed. Each of these lobes is inclosed in a distinct cavity 
QoGuhis.) Fig. 20, 4), has a separate excretory duct, and is subdivided 
a2;ain and again into smaller lobes, and ultimately into terminal lobules. 
Within the latter, by a process of cell development, and multiplication 
of nuclei, the milk is eliminated from the surrounding vessels. The 
fluid, on the rupture of the cells, passes into the terminal ramifications of 
the ducts ; which by their junction form larger canals termed galactoplw- 
rous ducts. The milk being thus brought from the various lobes, these 
ducts, from fifteen to twenty in number, converge towards the areola 
beneath which they become considerably dilated into sinuses, 6, which 
serve as temporary reservoirs for the milk. Between this and the nip- 
ple, the ducts again become contracted, 5, and proceed from the base of 
the nipple towards its summit without communicating, each discharging 
its contents by a special orifice. The walls of the tubes and sinuses are 
composed of areolar tissue, with longitudinal and circular elastic fila- 
ments. Irritation of the nipple, either by contact of the child's mouth 

' These appearances are materially altered after impregnation. See Signs of Preg- 
nancy, Chap. viii. 



36 



FEMALE ORGANS OF GENERATION. 



or otherwise, causes a relaxation of the orifices, and, at the same time, 
contraction of the walls of the sinuses, causing the milk to flow abun. 
dantly. Not unfrequently, a spasmodic contraction takes place indepen- 
dently of any special excitement, the result being the involuntary expul- 



Fig. 20. 




Dissection of the lower half of the Female Mamma duriug the period of Lactation. (Luschka.) 

sion and loss of the milk. The well-known sympathy which subsists 
between the glands and other organs, such as the stomach and uterus, 
may give rise to similar phenomena ; whilst that which exists between 
the breasts of each side often results in the spasmodic emptying of one 
gland while the child is at the other. 

The lacteal vessels are lined throughout by a mucous membrane, con- 
tinuous at the nipple with the common integument, and which is invested 
by a tessellated epithelium. They are accompanied in their whole course 
by numerous lymphatics, which are connected intimately with those of the 
axilla and other neighboring parts. These lymphatics are believed to 
take up the watery portion of the milk, and it is supposed to be by their 
action that frictions are beneficial in cases where we wish to diminish or 
arrest the secretion of milk. They receive their blood from the internal 
mammary, axillary, and intercostal arteries. The veins form round the 
nipple a circle or plexus, which is usually called the cir cuius venosus of 
Haller. In the latter months of pregnancy, the pressure of the gravid 
uterus tends, as Mr. Nunn has pointed out, to increase from mechanical 
causes the quantity of blood in these vessels, and thus to promote the 
secretion of the gland. 

Fig. 21, from Henle, represents a section from a small lobule of the 
gland, magnified 60 diameters: I, shows the stroma of the connective 
tissue which supports the glandular structure ; 2, terminal ramuscule of 



THE INTERNAL ORGANS OF GENERATION. 57 

one of the gland tubes; 3, glandular vesicles. Fig. 22 sllO^YS several of 
the glandular vesicles, magnified much more highly, about 200 diameters. 
The secreting epithelial cells which line the vesicles are here represented, 
Tvhile the cavities contain a certain number of milk globules. 

Fig. 21. Fig. 22. 



'^^IfeiRvy?^ 





Structure of a Lobule of the Mammary Ultimate Glandular Vesicles 

Gland. of the Mamma. 

In the male, the mammary gland exists, but is rudimentary. Various 
anomalies in structure have been met with, such as two or three nipples 
on one gland, or an additional mamma or even mamnic^. In the latter 
case, the supernumerary glands are usually near their ordinary site, but 
sometimes they have been found in a distant part of the body — as the 
axilla, thigh, or back. 

The Internal Organs of Generation. These are the Uterus, the 
Fallopian Tubes, the Ovaries, with various ligamentous and other struc- 
tures intimately connected with them. 

The Uterios, when unimpregnated, and at mature age, is situated deeply 
within the true pelvis, between the bladder and the rectum in front and 
behind, and intimately connected at its lower part, as we have already 
seen, with the vaginal wall. The function which it has to discharge, is 
to receive the product of conception after it has passed through the Fal- 
lopian tube, and to maintain it within its cavity until, at maturity, it is 
expelled. The usual comparison of it to a pear, flattened from before 
backwards, gives one a very correct idea of its form. It is a hollow 
organ, with remarkably thick walls ; and is so placed in the centre of the 
pelvis, that its upper part looks upwards and forwards, and its lower or 
vaginal part downwards and backwards. It is generally assumed, as 
sufficiently correct for all practical purposes, although by no means ab- 
solutely accurate, that its axis corresponds with that of the pelvic brim, 
or, in other words, that its axis, if carried downwards, would pass at the 
same time backwards, and cut the horizon at an angle of 30°. 

The uterus is divided into two parts : the bodi/, which is much broader ; 
and the neck, which is nearly as long as the body, but much narrower. 
The point of division between these two parts is frequently indicated ex- 
ternally by a slight constriction. 

Till about the fourteenth or fifteenth year, this organ is of small size, 
but a considerable increase takes place at the period of puberty. In 



58 FEMALE ORGANS OF GENERATION. 

women who have borne children, its volume is permanently iDcreased, 
although it is sometimes found in advanced age to have resumed in some 
measure the appearance presented in early life. It is temporarily in- 
creased in size during a menstrual period ; but if examined during the 
interval, the virgin uterus will be found to weigh on an average about 
500 grains, and to measure, in length three inches, in breadth about two 
inches, and in thickness (/. e., from before backwards) one inch. Its 
situation varies according to age. In the foetus it is altogether above the 
brim, but from this position it gradually descends after birth, although it 
is not till the tenth year or even later that the fundus falls to the level of 
the brim plane. The uterus is, when healthy and normal, united with 
the surrounding parts by means of .certain structures to be described 
presently. The nature of this union is essentially lax, admitting of pretty 
free movement in all directions, which may easily be tested by the finger, 
and which enables it to accommodate its position according to the degree 
of distension of the neighboring hollow viscera. This laxity admits too 
of the free expansion of the uterus during the course of pregnancy, but 
unfortunately it may also give rise to certain displacements, Avhich will 
be duly considered in the proper place, in so far as these have a bearing 
upon the practice of midwifery. 

The axis of the virgin uterus must, therefore, be constantly changing, 
now backwards and now forwards, according as vesical or rectal disten- 
sion prevails. It is thus a matter of no little difficulty to determine what 
may be regarded as the normal axis of the uterus, and in all attempts 
which have been made by anatomists with this view, it has been usual to 
consider the parts to be in their normal relative position when the bladder 
and rectum are each moderately distended. The opinion which is usually 
adopted, and which is founded on estimates of this nature, is, as has 
been said, that the axis of the uterus is identical with the axis of the 
pelvic brim. It is admitted that, in many cases, and especially in those 
in which the vagina is very short, the fundus falls more or less back- 
wards so as to bring the uterine axis more into a line with that of the 
vagina, while in some cases the uterus is curved so that the body forms 
an angle with the neck. 

This bending of the uterine axis, instead of being admitted as an ex- 
ception, is recognized by many of the best authorities as the normal posi- 
tion of the womb, a view which careful personal observation leads us to 
confirm. It is a point of great importance, in making examinations on the 
living subject, that it should be clearly recognized that the finger, on a 
digital examination, approaches the os uteri in a direction corresponding 
to the axis of the vagina, which frequently forms nearly a right angle 
with the uterus. If this is overlooked, error is sure to creep into our 
calculations, as has evidently been the case in certain instances of inac- 
curate description of the anatomical relations of the womb. The opinion 
here expressed as to the position of the womb is in accordance with 
that of Kohlrausch, as shown in his plates, and is confirmed by Dr. 
A. Farre in his admirable essay in the Cyclopmdiaof Anatomy and 
Physiology^ from which the diagram (Fig. 23) is taken. According to 
these able observers, when the bladder b and the rectum c are mode- 
rately distended, the fundus of the uterus is directed upwards and for- 



THE UTERUS. 



59 




Diagram, showing relative position of Pelvic 
Viscera. (A. Farre.) 



^'ards, and the neck downwards Fig- 23. 

and very slightly backwards to- 
wards the orifice of the rectum. 
The relative heights of these 
parts are determined, it is as- 
sumed, by two lines : the one, 
a — a^ being drawn from the 
lower border of the symphysis 
pubis to the promontory of the 
sacrum, to mark the height of 
the fundus ; and the other, h — 6, 
carried from the same point an- 
teriorly to the lower margin of 
the fourth sacral vertebra be- 
hind, to mark the plane of the 
orifice of the uterus. The line 
c — c indicates the axis of the 
body of the uterus. The repre- 
sentation, therefore, given in Fig. 
23, is, as regards the position of 
the womb, probably nearly cor- 
rect, subject, of course, to numerous modifications, in consequence of 
its mobility, and the influence exercised upon it by neighboring organs. 

The interior of the uterus corresponds in some measure with its exter- 
nal surface. It is divided into two parts by a constriction not far below 
its middle, indicating the point at which the cavity of the cervix ends, 
and that of the body begins. This constriction, which is the usual cause 
of the difficulty experienced in passing the instrument known as the ute- 
rine sound, is called the os uteri internum^ the orifice communicating 
Avith the vagina being named the os tincce, os externum, or, more gene- 
rally, the OS uteri. In a profile section (Fig. 24) the anterior and 
posterior walls are shown to be almost in apposition, this being, however, 
more complete at the internal os, o. From this point the cavity of the 
body extends upwards to the fundus, while that of the cervix reaches 
downwards, and terminates at the external os. The neck of the uterus 
is divided, as will be observed, into two portions, upper and lower, by the 
point of reflection of the vaginal mucous membrane, the lower part being 
called the vaginal part of the cervix. Viewed thus, the os is composed, 
as may be noticed, of two lips, a, anterior, and p, posterior, of which the 
former is generally described as the longer. This, however, which is 
more apparent than real, is caused by the position of the uterus as re- 
gards the pelvis, which brings the anterior lip lower in the vagina, and 
thus makes it seem longer than it really is in reference to the long axis 
of the organs. The vagina reaches somewhat higher on the posterior 
than it does on the anterior lip. 

If we now make a transverse section as shown in the accompanying 
diagram (Fig. 25), it is to be noticed, in the first place, that the cavity of 
the cervix, as well as that of the body, is expanded from side to side, 
owing to the approximation of the anterior and posterior walls as shown 
in the previous figure. The cavity of the cervix then is, being somewhat 



60 



FEMALE ORGANS OF GENERATION. 



Its lining mem- 



flattened from before backward, irregularly fusiform, 
brane presents a peculiar appearance, being thrown into irregular folds, 
which branch laterally from a raph^ or median line, in a direction gene- 
rally upwards. This arborescent appearance has given rise to the name 



FiR. 24. 




Fig. 25. 




Profile Section of the Uterus. 



Transverse Section of the Uterus. 



under which it is known to anatomists, the arhor vitse uterinus^ and it has 
been observed that in the uteri of very young children, these folds are 
traced much higher than in the internal os, which is their limit in the 
adult. The cavity of the body is from this point of view triangular in 
shape, smooth on its surface, and having three openings leading into it, 
one at the internal os or apex of the triangle, and one at each angle of 
the uterus, leading right and left into the Fallopian tubes. Some rare 

instances of congenital absence of this 
Fig- 26. cavity have been recorded : what is more 

common is adhesion of the walls in old 
age. 

The OS uteri, as felt by the finger, or 
as seen through the speculum, is a trans- 
verse opening or slit, which, in the virgin, 
and in the absence of structural disease, 
is perfectly smooth. In these circum- 
stances, the aperture is closed, but the 
depression between the lips is easily felt, 
and is precisely similar, in the impression 
it communicates to the finger, to the sen- 
sation experienced when the finger is applied to the tip of the nose. In 
this case the cartilages represent the firm tissue of the lips, while the 
vertical interval between them corresponds to the transverse slit which 
constitutes the os. 




Os uteri. 



RELATIVE POSITION OF PELVIC ORGANS. 61 

The characteristics above described are those of the virgin, or, as Dr. 
Tjler Smith more correctly calls it, the " nulliparous" uterus. During 
pregnancy, the orc^an is enormously distended, and the anatomical rela- 
tions of the contiguous parts are greatly disturbed. After delivery, the 
parts contract, and regain in a great measure their original appearance 
and condition, but they nevertheless retain features of dissimilarity, ^vhich 
generally enable the observer, on a careful examination, to distinguish 
the uterus of a woman who has been a mother. The chief points of dis- 
tinction are as follows : The weio:ht of the oro;an is increased, according; 
to ^leckel, to about an ounce and a half; the fundus and body are 
rounded externally ; the cavity of the body loses its triangular shape, 
and becomes much larger relatively to the cervix, the os internum being 
agape. The arborescent folds of the cervix are in a great measure ob- 
literated, or at least are rendered indistinct, and the os externum is patent. 
The diiferences in the latter are, from the fact of its being of easy ac- 
cess to the finger, of special importance, and consist mainly in an enlarge- 
ment of the parts, and an irregularity in the surface of the lips, which 
are now no longer smooth, but puckered round the edge of the os, and 
often nodulated on the surface. These irreo-ularities are due to slio;ht 
lacerations of tissue which occur during delivery. They are always 
more marked in women who have borne many children, where the lips are 
not unfrequently divided into lobes by shallow furrows, representing these 
lacerations, and which radiate from the os as from a centre. These fissures 
are generally observed at the sides or angles of the os, and are, accord- 
ing to Cazeaux, much more marked on the left than on the right side. 

The uterus, then, as may be inferred from what has been said, presents 
a fundus, more or less rounded according as the woman has or has not 
borne children, two borders laterally, and an anterior and posterior sur- 
face, of which the latter is the more convex. It consists of three con- 
stituent layers : a serous or investing coat ; a mucous or lining coat ; 
and an intermediate thick layer of fibro-muscular structure constituting 
the proper tissue of the uterus. Each of these requires special and very 
careful consideration. 

The Serous Coat. — Along with this, we shall consider certain struc- 
tures very intimately connected w'ith it w^hich are described as the Liga- 
ments of the Uterus. The great serous membrane, which invests almost 
the whole of the abdominal viscera, is also reflected over the greater part 
of the womb. Passing backw^ards over the fundus of the bladder, the 
peritoneum becomes reflected upwards on the anterior surface of the 
uterus from a point which in the virgin uterus is about midway between 
the OS externum and internum, a space being thus left (see Fig. 19) 
through which direct communication may take place between the uterus 
and the bladder. This may occur as an accident in midwifery practice, 
constituting a vesico-uterine fistula, as in a case reported by the writer.^ 
From the front to the back of the uterus, the membrane now passes over 
the fundus, and investing the whole of the posterior surface with the 
exception of the vaginal portion, reaches downwards behind the vagina, 
in the manner already described, to form the pouch of Douglas. The 

' Glasgow Medical Journal, 1862. 



62 



FEMALE ORGANS OF GENERATION 



manner in which the uterus is thus embraced by the peritoneum in its 
course from before backwards is peculiar. Instead of investing the 
lateral parts of the organ in the same manner as the anterior and pos- 
terior walls, it is stretched from side to side of the pelvis, forming, in 
fact, a double layer of peritoneum, in the centre of which the uterus is 
confined. These folds, intimately connected on either side with im- 
portant organs to be presently described, are the broad ligaments of the 
uterus. 

Looking from above downwards (Fig 27) in the axis of the brim, it 
will bo noticed that the broad ligaments, with the uterus u^ form a parti- 



Fig. 27. 




Pelvic Organs in situ, viewed in the Axis of the Brim. (After Schultze.) 

tion or curtain, dividing the cavity of the pelvis into two parts, anterior 
and posterior, of which the anterior is occupied mainly by the bladder, 
5, and the pouch which separates it from the womb, and the posterior by 
the rectum, r, and the pouch of Douglas. It will also be observed that 
the greater convexity, and, indeed, the bulk of the uterus, projects into 
the posterior of the two cavities. The attachment of the broad ligament 
is, in point of fact, to the anterior lip of the lateral border of the womb. 
If, therefore, the uterus and the broad ligament are viewed from 
before, as in Fig. 28, the fundus and body of the uterus are indeed 
indicated, as well as the situation of other parts to be mentioned imme- 
diately, and the relation which they all bear to the vagina ; but the parts 
themselves are only to be distinctly demonstrated by turning our atten- 
tion to the posterior surface of the pelvic partition, as shown in Fig. 29, 
where the posterior wall of the uterus has been removed, in order to 
show the interior of the organ. The peculiar structure of the cavity of 
the cervix, the anterior lip of the os, and the anterior wall of the vagina 



LIGAMENTS OF UTERUS 



63 



are also shown, as also the triangular space bounded inferiorlj by the 
ovary and its ligaments, which, from a fanciful resemblance to a bat's 
wing, has been called ala vespertilionis. 



Fiff. 28. 




'j \ • .v\ V 

Anterior View of the Uterus and its Appendages. (Quain.) 

It is thus very apparent that the effect of the broad ligament is to 
maintain the uterus in its central position as regards the pelvic cavity, 

Fiff. 29. 











Posterior View of the Uterus and its Appendages. (Quaiu.) 

and to prevent its displacement downwards, while it admits of very free 
antero-posterior movement, corresponding to the distention of the bladder 
or rectum. 

Between the two layers w^hich constitute the broad ligament, and 
occupying each a fold more or less distinct, are the following structures: 
the round lif/ament (see Fig. 27), a cord-like bundle of fibres, partly 
muscular, and about four and a half to five inches in length, w^hich has 
its course on each side from the angle of the uterus, first upwards 
and outwards, and then forwards and a little inwards to the internal 
inguinal ring. Passing, like the spermatic cord in the male, through 
the inguinal canal, and invested by a peritoneal sheath called the 



64 FEMALE ORGANS OF GENERATION. 

canal of Nuck, its fibres expand and are lost in the mons veneris, 
some of them having been traced to the purse-shaped cavity in the 
labia majora already described. According to Madame Boivin, the 
ligament of the right side is a little shorter and thicker than the other. 
Two small semilunar folds are seen on this aspect, which are formed by 
the peritoneum in its passage from the uterus to the bladder, and which 
limit laterally the pouch existing between these two organs. They are 
called the vesico-uterine ligaments. The uterus is generally observed 
to be a little more to the right than to the left side ; and it is asserted 
by Schultze that, in the normal position, it is somewhat twisted on its 
axis so as to turn the anterior surface a little to the right. On this 
observation is grounded a theory which Schultze has propounded as to 
the position of the child in the womb. All this is shown in Fig. 27. 

Reverting now to the posterior surface of the broad ligament, we find 
several parts Avhich are of the highest physiological importance. At the 
upper or free margin of the broad ligaments, and occupying a portion of 
the space between its layers, there extends from each angle of the uterus 
a thick cord, between three and four inches in length, at first nearly 
straight in its direction, but in its outer half pursuing a somewhat tor- 
tuous course, especially in young subjects. This is found, on dissection, 
to be traversed in its whole extent by a canal of small diameter, and is 
familiarly known to anatomists as the Fallopian tube (^oviduct'). It is 
composed in a great measure of muscular tissue of the non-striated 
variety, which is disposed in layers, an external one of longitudinal, and 
an internal of circular fibres. Along with this is areolar tissue, the 
whole being embraced by the peritoneum in the manner described. The 
canal is lined with mucous membrane, with an epithelium of the columnar 
and ciliated variety, continuous at one extremity with the mucous mem- 
brane of the uterus, and at the other with the inner surface of the peri- 
toneum — a unique example of a mucous being continuous with a serous 
membrane, and of a serous cavity which is not absolutely a closed sac. 
The tube is small, and its cavity narrow at the uterine end, barely per- 
mitting the passage of an ordinary bristle, but it becomes dilated in its 
course outwards, and ultimately expands into the trumpet-shaped ex- 
tremity from which it derives its name (tuha^. The mucous membrane 
lining the canal is disposed in longitudinal folds, so that in a transverse 
section of the structure the cavity presents a stellated appearance. The 
mouth of the tube has a very irregular and fringed margin, hence its 
name of fimbriated extremity — the fimbriae being arranged in a circular 
manner, and surrounding the orifice, which looks downwards in the 
direction of the ovary. With this organ it is in fact connected by an 
'elongation of one of the fimbriae. When the ovum comes to maturity 
within the ovary, that portion of the organ from which it is about to 
escape by dehiscence is firmly grasped by the fimbriae (inorsiis diaboW)^ 
and the ovum is received into the oviduct, and by it conducted to the 
uterus, where it is retained and developed, or w^hence it is discharged, 
according to circumstances. 

Leading from the inner extremity of the ovary — an organ to be here- 
after described — is a dense cord, composed mainly of fibro-areolar tissue, 
but containing also muscular fibres. This is the ligament of the ovary ^ 



LIGAMENTS OF UTERUS, 



65 



which is also, like the round ligament and the Fallopian tube, firmly 
united to the angle of the uterus at a point behind and below the latter, 
and is about an inch and a half in length. The parovarium or Organ of 
Rosenmiiller (Fig. 30, jt? o), is situated between the layers of the broad 
ligament, and can usually be brought into view by holding up to the 
light that portion of the ligament which is between the outer part of the 

Fiff. 30. 




Diagrammatic View of the Uterus and its Appendages as seen from behind. (Quain.) 

ovary and the Fallopian tube. According to the observations of Kobelt 
and FoUin, the parovarium is usually composed of from seven to ten 
tubules, which are convoluted and end in a cul-de-sac, all converging 
towards the tube through which the vessels of the ovary pass. These 
tubes exist at all ages, but are more distinct in children, and still more 
so in the foetus. In no instance have they been found to have an orifice, 
but there seems good reason to believe that they correspond to the epi- 
didymis of the male, more especially the coni vasculosi, and are therefore 
the vestiges of the upper part of the Wolffian bodies of the embryo. It 
is more than likely that the cysts which so frequently originate in this 
situation, have some anatomical connection with the parovarium. From 
the back of the uterus on each side, crescentic folds of peritoneum pass 
backwards towards the rectum (Fig. 27). They are more marked than 
the vesico-uterine folds, previously described, and are called the poste- 
rior or recto-uterine ligaments, or folds of Douglas, as they mark the 
upper boundary of the pouch with which the name of this anatomist is 
associated. 

That muscular fibres exist between the layers of the broad ligament is 
a question no longer open to doubt ; and there seems good reason to 
believe, from the researches of Rouget and others, that this is only a 
portion of a continuous envelope of muscular fibres, embracing the uterus. 
Fallopian tubes, and ovaries. These fibres are believed to exercise, an 
important physiological function, in bringing all the structures into har- 
monious action, and more especially in insuring the precision with which 
the fimbriated extremities of the Fallopian tubes grasp the ovaries. 

The uterus is thus — by means of its ligaments and other auxiliary 
structures — so suspended in the cavity of the true pelvis as to admit, as 



66 FEMALE ORGANS OF GENERATION. 

has been shown, of tolerably free movement, and, at the same time, to 
restrict its mobility within certain limits. The movement of the body 
from side to side is curtailed effectively in a healthy state of the parts, 
by the broad ligament, while displacement backwards is prevented by 
the vesico-uterine folds and the round ligament, and movement in the 
contrary direction by the recto-uterine ligaments. Undue importance 
must not, however, be attached to the functions of these structures as 
ligaments ; for it is very obvious that other parts (and in an especial 
degree the vagina) aid them in holding the uterus thus in suspension. 
The general laxity of all these tissues, however, which nature permits in 
view of the higher function of the uterus, is very apt, under disturbing 
influences, to give rise to displacements which have already been referred 
to, but the consideration of which belongs more properly to the depart- 
ment of gynaecology. It may, however, be observed that the symptoms 
of these displacements are, in a great measure, mechanical, and the 
direct result of the loss of equilibrium — as those, for example, which 
arise from pressure on the bladder or rectum, and the pain in the groin 
frequently experienced in retroversion, which is assumed by Cazeaux to 
arise from tension of the round ligament. 

In the interval between the two layers of the broad ligament, and 
associated with the other structures above described, there is found a 
considerable quantity of loose and extensible cellular tissue. This admits 
of the complete alteration in the anatomical relations of the parts which 
occurs during pregnancy, and this is further provided for by the manner 
in which the uterus is attached to its serous investment. The nature of 
the connection is firm at the fundus, and lax at the sides, where the peri- 
toneum may be moved by the finger to and fro upon the subjacent tissue 
of the organ. The manner in which the neighboring parts accommodate 
themselves to the distension of the womb during pregnancy will fall to 
be considered in a subsequent chapter. 



CHAPTEE lY. 

FEMALE ORGANS OF GENERATION (Continued). 

Of the Proper 7\ssue of the Uterus. — Of the Mucous Laijer : its Structure and 
Glands, in the Body and Cervix. — Bloodvessels of the Uterus. — Lymphatics 
and Nerves. — Malformations and Ahnormal Conditions. — The Ovaries: their 
Structure. — The Graafian Vesicles and their Development. — The Ovum. — 
Phenomena of Ovulation. — Formation of the Corpus Luteum. — The Corpus 
Luteum of Pregnancy distinguished. 

The Proper Tissue^ which lies immediately beneath the peritoneum, 
and which constitutes the greater part of the walls of the uterus, is very 



MUCOUS MEMBRANE OF UTERUS. 



67 



dense in structure, and, except during pregnancy or a menstrual period, 
is of a grayish color in section, and displays numerous bloodvessels, some 
of them of considerable size. It is thickest at the middle of the body 
and at the fundus, thinnest at the Fallopian tubes, and is composed 
throughout of bundles of muscular fibres of the plain variety. These 
fibres in the unimpregnated condition are interlaced, disposed very 
irregularly in bands and layers, and mixed with fibro-areolar tissue, 
-which is more abundant near the external surface. As in the case of 
other hollow viscera, the muscular elements may be described as consist- 
ing of an external layer, the fibres of which have a general longitudinal 
direction, and of an internal or circular layer. From the irregular man- 
ner, however, in which, in the unimpregnated uterus, the bundles of 
fibres are disposed, and the intimate union which subsists between them, 
this seems on the first glance to be somewhat of a forced analogy. And 
it would probably remain -so, were it not that during pregnancy the 
stratification of the muscular tissue becomes much more distinct, so as to 
render the comparison quite justifiable, a fact which will be brought out 
more clearly afterwards. Anatomists usually divide this tissue into 
three layers, external, intermediate, and internal. 

Mucous Memhrane — The very existence of this membrane was long 
disputed, the obvious reason being that it differs so much from other 
mucous membranes, that physiologists, with some show of reason, refused 
to admit the analogy. More modern and more exact observations, how- 
ever, leave no doubt as to the propriety of classifying it as it is here 
named. Tlie descriptions which are usually given of this membrane by 
anatomists are very meagre, and in some respects inaccurate ; this may 
serve as our warrant for examining its structure and functions a little 
more in detail than under other circumstances might have been necessary. 
It is probably the thickest mucous membrane in the body, constituting, 
in the cavity, about one-fourth of the entire thickness of the organ. In 
this situation, it is of a reddish tint, but in the cervix, where it is much 
thinner, it is paler in color, the thinning occurring somewhat abruptly at 
the OS internum. It is firmly adherent to the subjacent muscular tissues, 

Ficr. 31. 




Tubular Glands of Uterus. (E. H. Weber.) 



and cannot, in consequence of the sparseness of the submucous cellular 
tissue, be made to glide upon the part which it covers. The surface of 
the membrane is smooth, and abundantly studded over with minute dots, 
which are found on closer examination to be the orifices of numerous 
tubular glands, which run through the entire thickness of the membrane 



68 



FEMALE OEGANS OF GENERATION, 



Fiff. 32. 




in a direction perpendicular to its surface. Fig. 31 represents a part of 
the cavity of the uterus which shows in section the orifices of the glands 
(a), and the glands themselves (d). They were believed by Weber to be, 
at the commencement of pregnancy, greatly convoluted, and sometimes 
bifurcated at the extremities, as here represented. The more recent and 
exact observations of M. Robin show, however, that when in situ, they 
are rather undulated than convoluted, that they are never spiral, al- 
though, as in Fig. 32, they may appear so when separated, and that they 
never bifurcate. During pregnancy and menstruation, they become 
greatly enlarged, and sometimes cross each other, an appearance which 
in all probability has led to the idea of a division of the tube. They are 
simple tubular glands, parallel to each other, ending in a 
cul-de-sac, and penetrating the entire thickness of mem- 
brane. They are lined by nucleated ovoid epithelial 
cells, their walls being finely granular, and very firmly 
adherent to the tissue which intervenes between them. 
Their length measures exactly the thickness of the 
mucous membrane, and is much less, therefore, where 
the membrane becomes thinner, on its approach to the 
OS internum and the orifice of the Fallopian tubes. " If 
we except that of the stomach," says M. Robin,^ " there 
is no mucous membrane more rich in glandular follicles 
than that of the uterus." In the pig and some other 
animals the epithelial cells which line the glands are 
ciliated. 

In the unimpregnated uterus, in an inter-menstrual period, the tubular 
glands are not very easily seen ; but if their sections are treated with 
acetic acid or concentrated tartaric acid, and viewed by transmitted light, 
they can generally be made out. They terminate quite abruptly at the 
inner margin of the muscular coat, the point of junction being very dis- 
tinctly indicated by the muscular fibres running at right angles with the 

tubes. The glands were supposed 
Fig. 33. })j Sharpey to penetrate the mus- 

cular tissue, but this view is now 
generally regarded as an erroneous 
one. Their abrupt termination is 
well shown by a reference to Fig. 
33. In the same preparation, 
which was taken from the uterus 
of a young girl who had commit- 
ted suicide in the inter-menstrual 
period, is also shown the general 
direction of the fibres composing 
the proper tissue of the uterus, |>, 
as compared with the course of the 
tubules from the free surface of the 
mucous membrane at m. At a the tubes are cut across, and shown ob- 
liquely m section, and the course of the bloodvessels which accompany 



Tabular Gland of the 
Uterus. (Coste.) 




Eelation of Tubular Glands to Muscular Tissue 
of Uterus. (Coste.) 



1 De la Muqueuse Uterine. Paris, 1861. 



MUCOUS MEMBRANE OF UTERUS, 



69 



them is also indicated between m and the adjacent part of the muscular 
tissue. 

Fig. 34, also taken from Coste's beautiful plates, shows a detached 
portion of the mucous membrane in the same case. Little funnel-shaped 
depressions are shown at «, into which the orifices of the tubes open. 
The actual glandalar orifices are distinctly shown elsewhere on the sur- 
face of the membrane. From one portion, the epithelium has been stripped 
oft", so as to show the termination of the tubes free and floating. But 

Fio:. 35. 





Termination of Tubular Glands on 
Mucous Surface of Uterus. 



Tubular Orifices of 
Uterus. (Sharpey.) 



what is most distinctly shown here, is the perfect net-work of vessels 
which surround the orifices, which is always to be observed most distinctly 
at those seasons when the functional activity of the uterus is excited. 

Fig. 35 is a small portion of the mucous membrane as observed after 
recent impregnation. This specimen is represented as viewed upon a 
dark ground, and also shows the orifices of the uterine glands, in most 
of which, as at 1, the epithelium remains, and in some, as at 2, it has 
been lost. 

The mucous membrane is smooth on its surface, which is composed of 
columnar and ciliated epithelium. Cruveilhier describes it, however, as 
presenting indistinct papillae, while some earlier physiologists insist that 
it is studded with free villi: errors which hav^e probably had their origin, 
as ^I. Robin assumes, in the extremities of the glandular follicles becom- 
ing liberated from their epithelial attachment by jjost-mortem change, and 
which find in analogy an apparent corroboration in the condition of the 
membrane as observed in the uterine cornua of some mammalia. During 
pregnancy the epithelium becomes transformed ; it loses all trace of the 
vibratile cilia, and the cells are changed from the columnar to the pave- 
ment variety. 

Berres' was the author of the erroneous hypothesis that the villi of the 
placenta plunged into these glands to be there bathed in materials des- 
tined for the foetal blood, a view which was afterwards supported by 



Medicinische Jahrbiiclier des K. K. (Esterreicli. Staates. Wien, 1837. 



70 FEMALE ORGANS OF GENERATION. 

Bischoff,^ but which now receives little if any support. M. Coste^ was 
undoubtedly the first who gave a complete description of the mucous 
membrane during menstruation and the various stages of pregnancy. To 
him the merit is also due of having demonstrated, what is now all but 
universally admitted, that the maternal covering of the ovum (decidua)^ 
of which we shall have more to say, is not a new formation, as Hunter 
taught, but is the mucous membrane itself, altered and modified to suit 
the circumstances of the case. The views of Coste have received the 
most remarkable confirmation by the subsequent observations of Richard, 
and by the still more recent researches of Robin. 

The mucous membrane of the uterine cavity is continuous at the 
angles with that which lines the Fallopian tubes. At the internal os, it 
becomes much thinner, with fewer glands, and loses many of its special 
characteristics as it passes into the cavity of the cervix. The presence 
of the folds, which give to it in this situation an arborescent appearance, 
has already been noticed. The extent of the inner surface of the cervix 
is thus greatly increased, an arrangement which not only admits of free 
dilatation of the parts, but also furnishes a greatly increased secretory 
surface. It has been computed by Dr. Tyler Smith that, in a well- 
developed virgin uterus, the follicles of the cervix (^glanduloe Nabotlii) 
are not less in number than ten thousand. These glands secrete a clear 
tenacious fluid, which is alkaline in reaction, and which is often seen on 
vaginal examination to occupy the os externum, and they are liable 
during pregnancy to a very remarkable hypertrophy. The mucus which 
lubricates the parts during delivery is partly derived from this source, 
and in certain morbid conditions it is greatly increased in quantity, when 
it is either secreted of an acid reaction, or loses its alkalinity, and also 
its transparency, by contact with the acid mucus of the vagina. The 
cavity of the cervix is lined with an epithelium which in its lower half is 
squamous like that of the vagina. About midway between the outer and 
inner os, it assumes the characteristics of the ciliated and columnar epi- 
thelium of the cavity. 

The uterus is supplied with blood from two sources. The ovarian 
arteries have their origin, like the spermatic in the male, from the aorta, 
at a point a little below the renal aiteries. Passing over the psoas 
muscles, and occupying a fold in the peritoneum, which is indicated in 
Fig. 27, they pass between the layers of the broad ligaments — forming 
what have been described as the ovario-pelvic ligaments. They follow, 
in their passage towards the ovary, an extremely tortuous course, which 
admits of free distension during pregnancy without any risk of diminu- 
tion of their calibre. Giving off branches to the ovary and round liga- 
ment, they now pass inwards to join the uterine arteries on each side. 
These latter spring from the anterior division of the internal iliac, pass 
between the layers of the broad ligaments downwards towards the neck 
of the uterus, then upwards, pursuing, like the others, a very tortuous 
course, and, giving oif numerous branches to the uterus, effect a union 
Avith the ovarian arteries. Frequent anastomoses take place, and the 

' Traite du developpement de I'liomme, etc., Paris, 1845. 

2 Histoire du developpement des Corps Organises. Paris, 1847. 



BLOODVESSELS OF UTERUS. 71 

branches may be seen to lie in little canals or channels on the surface of 
the womb, before they penetrate more deeply. The veins correspond to 
the arteries just named, and are of considerable size. They form 
plexuses, which communicate freely, and during pregnancy their calibre 
becomes enormously increased. Within the substance of the uterus, the 
ramifications of the arteries retain their spiral form, but become straighter 
as they approach the mucous membrane, where fine branches surround 
the tubular glands, and ultimately form, as has been shown (Fig. 34) a 
fine network on the free surface of the membrane. The veins which 
convey the returning current are, at their origin, of small size, but be- 
come much larger within the substance of the womb, attaining during 
pregnancy a size so considerable that they are designated the uterine 
sinuses. The cervix is less vascular than the body and fundus. 

Numerous lymphatics, which are fully developed only during preg- 
nancy, have been traced to the uterus. Some doubt still exists, how- 
ever, as to the precise source of the nervous supply. All agree that the 
chief supply is from the sympathetic system — the hypogastric, renal, and 
inferior aortic plexuses being all believed to contribute. The idea gene- 
rally entertained is, that the sacral nerves send some filaments to the 
cervix, and to the cervix only. This has been denied by Dr. Snow 
Beck,* and it has even been asserted by M. Jobert that no nerves what- 
ever are sent to the vaginal portion of the cervix, but a study of the 
nervous supply in the case of other hollow viscera would lead us to infer, 
by analogy, that the idea above expressed is correct. 

While, as a rule, in the Mammalia, the vagina is single, the contrary 
is the case as regards the womb. In the female human embryo, the 
uterus is formed by the median fusion of the lower parts of the ducts of 
Miiller — which are the efferent tubes of the rudimentary generative ap- 
paratus. These meet together inferiorly, become gradually united from 
below upwards, and ultimately form a single cavity by the absorption of 
the partition between the two, so that there is a stage in development, at 
which the human uterus is composed of two separate and distinct tubes. 
It follows, from the manner in which they become united, that there is a 
series of subsequent stages at which the partly developed organ may be 
termed uterus hicolUs — when the necks are still separate ; bicorporeus — 
w^hen the union has reached the os internum; hifundalis — when the 
fundus alone is divided ; and, finally, the uterus simplex — the highest or 
perfect human form. In the other Mammalia, the process is so far iden- 
tical, but may be arrested at any stage to form the uterus natural to the 
group to which the individual belongs. In the Marsupials, not only are 
the two uteri separate, but also the vaginae. In a large number of the 
Rodents, the vagina is single, and into its fundus two distinct uterine 
cavities open by separate apertures ; while, in some, there is a partial 
division in the vao;ina for about a third of its leno;th. The commencino; 
union of the cervix is shown in some groups of the same order — as the 
Muridge — where there is a very short comaion cavity. The confounding 
of the two uterine cavities may be traced in various progressive stages 
by an examination of the internal organs of certain of the Carnivora, the 

1 Philosophical Transactions, London, 1846. Part IL, p. 219. 



72 FEMALE ORGANS OF GENERATION. 

Ruminants, the Ungulata, the Edentata, and the Simiadse ; but even in 
women there still remains in the angles of the uterus a trace of the 
original bifurcation. 

This reference to the development of these parts, and, for the analogy, 
to their condition in the lower animals, will be found to throw light upon 
certain cases of malformation or peculiarity of structure in the human 
subject, which apparently consist, for the most part, of a simple arrest of 
development. Taking the particulars above noted as a basis of classifi- 
cation, we may adopt the division in regard to those abnormalities which 
Dr. A. Farre, in his Essay on the Uterus,^ has selected as the best. Of 
this section of his admirable monograph, the following remarks are in 
great part an abstract. 

G-roup 1. Complete absence of the uterus, both of the ducts of Miiller 
being imperfect or undeveloped. In the cases of total absence of uterus 
which have been recorded, it seems certain that, in a very large propor- 
tion at least, something of a rudimentary organ existed in the fold of the 
peritoneum lying behind the bladder, and representing the broad ligament. 
These rudimentary structures usually occur under the form of two hollow 
rounded cords, or bands of uterine tissue, extending upwards towards 
the ovaries. The vagina may be absent or rudimentary, as also the 
Fallopian tubes ; but it is interesting to observe that the ovaries may be 
perfect in these cases — a fact easy of explanation, when we remember 
that the ovary is formed out of a separate portion of blastema from the 
Wolffian bodies and duct of Miiller. 

Group 2. One uterine cornu only may retain the imperfect condition 
last described, while the second develops, so that we now have what has 
been called the uterus unicornis. In this condition, which represents 
the type of the normal condition in birds, both ovaries may be found 
perfectly developed. 

Group 3. When development progresses in both cornua, and these do 
not, as under ordinary circumstances, unite, various peculiarities result, 
which cause the uterus to assume, according to the degree of the malfor- 
mation, a type which is lower or higher in the animal scale. " The mar- 
supial type," says- Owen, " is repeated in one of the rarer anomalies of 
the female organs in the human species." This, indeed, is an anomaly 
so rare and peculiar, that it has only been observed as coexistent with 
other malformations — such as fissure of the abdominal and pelvic walls ; 
but what is more frequently met with is the form shown in Fig. 36, where 
the two uterine halves meet, and are united by a commissure of true 
uterine tissue, which represents the fundus uteri. The higher this com- 
missure reaches the more does the womb approach to the normal type. 
In the figure there are two vaginae, two orifices, and two uterine cavities. 

In the cases shown in Fig. 37, there is but one vagina. The os also 
is single, as is the cavity of the cervix, the bifurcation commencing about 
the OS internum. The angle at which the cornua unite varies in different 
cases — which is accounted for, as is pointed out by Rokitansky, by the 
height at which the uniting commissure is situated. 

Group 4. In this, the external form of the uterus differs but little 

' "Cyclopaedia of Anatomy and Physiology." London, 1859. 



UTERINE MALFORMATIONS, 



io 



from the normal character. The breadth of the organ is greater, espe- 
cially at the fundus, where a depression in the middle line indicates the 
situation internally of a vertical septum, which more or less completely 
divides the uterine cavity into two halves, and constitutes the uterus 



Fiff. 36. 



Fig. 37. 




Double vagiua and Uterus. (After Busch.) 



Bifid Uterus. 



hilocularis. The extent of this septum may vary from a mere ridge to 
a complete partition, which may even invade the vagina. 

These several deviations from the normal form of the uterus will 
influence more or less the function of the organ. Menstruation may, 
it is true, in a large proportion of cases, be scarcely affected ; and this 
function will be normally discharged whenever the ovaries are perfect 
and an adequate channel exists. In those rarer cases, however, in Avhich 
the uterus is rudimentary, there may be perfect ovaries, and atresia 
either of the cervix or of the vagina, with the result, if a uterine cavity 
exists, of an accumulation of the discliarge, and attendant symptoms of 
considerable severity. If, on the contrary, there be no cavity, the 
menstrual molimen may then be relieved by the occurrence of vicarious 
discharges. As regards the influence exercised by such anomalies upon 
impregnation, much will depend upon the condition of the vagina, and 
also of the Fallopian tube, for, if either of them are closed, impregnation 
is of course impossible. If, however, they are open, it is quite possible 
for impregnation to occur even in a uterus unicornis.^ 

Great difficulty and danger may arise, in such cases, during the pro- 
gress of gestation. In the case, for example, which is referred to in the 
foot-note, death took place from rupture of the sac in the third month, 
the termination being thus very much what one would expect in a case 
in which the development of the ovum goes on in the Fallopian tube, 
instead of in the cavity of the womb. In the cases of the uterus bicornis 
and hilocularis, either side of the uterus may become separately or alter- 
nately the seat of gestation, or twins may be simultaneously developed, 
one on each side. There is, indeed, no good anatomical ground for 



' See a remarkable case by Rokitansky, tlie preparation of wliicli is in the Vienna 
Museum. (Pathological Anatomy — Syd. Soc, vol. ii. p. 277.) 



74 FEMALE ORGANS OF GENERATION- 

absolutely rejecting the doctrine of superfoetation as a possibility in such 
cases. When there is a double vagina, coition usually takes place by 
one canal, so that successive pregnancies may be looked for on the same 
side. The effects produced on the act of parturition by such anomalies 
as have been cited, have probably been exaggerated. Rokitansky has 
indeed shown that the axis of expulsion may, as in the one-horned 
variety, be so directed as to place the forces at an obvious disadvantage ; 
but it may be assumed that, if the anomaly has been of such a grade as 
to admit of complete intra-uterine development, there will not likely be 
any impediment during delivery, which may not be surmounted by the 
application of ordinary principles. 

Cases in which the arrest of development has taken place after birth 
are to be placed in a special category. At the ordinary period of 
puberty, the signs which indicate sexual maturity do not appear, while 
the uterus is found still to present the characters peculiar to infancy or 
childhood. In these cases, which are almost certainly productive of 
sterile marriages, there is often an absence of the vaginal portion of the 
cervix ; and the other infantine conditions of the womb may be exhibited 
in every particular, such as the exaggeration of the forward curve which, 
in a smaller degree, we have indicated as the normal adult condition, the 
persistence, within the cavity, of rugae similar to those of the cervix, and 
the thinness of the parieties. 

Tlie Ovaries. — Projecting on either side from the posterior surface of 
the broad ligament, and invested with a special fold of its posterior 
layer, are the important organs within which is elaborated that which 
the woman contributes to the propagation of her species, analogous 
therefore in this, as in other respects, to the testicles of the male. They 
are connected (see Figs. 27, 28, and 29) with the uterus by a special 
ligament already described, and also through the Fallopian tubes, to one 
of the fimbriae of which they are permanently adherent. In shape, the 
ovary is a flattened oval. It varies greatly in size, according to age, and 
in different individuals of a similar age ; but it may be set down as, on 
an average, about eighty grains in weight, and an inch and a half in 
extreme length. From the manner in which it is embraced by the peri- 
toneum, it is free on two sides, and on the posterior border, and is 
attached to the broad ligament by a kind of mesentery along the ante- 
rior border only, where, between the layers, the vessels and nerves 
enter. The nature of the relation subsisting between the ovary and the 
peritoneum has of late been a subject of much interest to physiologists, 
and the observations of Waldeyer^ certainly now leave no room for 
doubt that anatomists have been in error in describing the ovary as 
invested by the peritoneum in the same manner as the other viscera. 
The structure of the peritoneum proper ceases abruptly at a fold near 
the hilus, quite visible to the naked eye. This fold surrounds the 
ovary in such a way that the greater portion of its free surface consists 
not of the peritoneum, but of a special layer, continuous with the peri- 
toneum, presenting, on microscopic examination, a prismatic epithelium 
instead of the laminated form which exists in the serous membranes. 

1 Eierstock uiid Ei. Leqjzig, 1870. 



THE CxRAAFIAN VESICLES. 75 

This prismatic epithelium is intimately connected ^Yith the origin of the 
ova. The ovary attains its greatest size after puberty, and is, up to this 
period, smooth on the surface. During pregnancy, the position of the 
organ is completely changed ; but, in the unimpregnated condition, it 
will be found lying deeply in the lateral posterior part of the pelvic 
cavity, covered by the small intestines, and to some extent by the 
Fallopian tube of the same side. Beneath the outer covering, a dense 
layer of the stroma, somewhat white in color from a sparseness of blood- 
vessels, binds the proper structure of the organ together, giving support 
and protection to it, and to the important structures which it contains : 
this is the tunica alhugmea. The bulk of the organ beneath this is 
composed of highly vascular tissue of a pinkish color, which is called 
the stroma of the ovarj^ The stroma is composed of a dense fibro- 
nuclear tissue, through which bloodvessels ramify from the base of the 
ovary towards its surface. 

The G-raajian Vesicles. — If a longitudinal section is made through a 
mature and healthy ovary, these vesicles are brought into view, imbedded 
in the stroma and varying considerably in size. In number and in situa- 
tion, they differ greatly according to age. In infants and young children, 
the ovary is found to be composed, within the tunica albuginea, of two 
distinct portions — one internal, corresponding to the stroma in the mature 
organ, and the other external, of considerable thickness and density. It 
is in the latter, or peripheral portion alone, that, at this time, the 
Graafian vesicles are to be found, in enormous numbers, but as yet of 
small size and in a rudimentary condition. Each is, as a rule, occupied 
by one young ovum, and it has been computed by Foulis^ that at birth 
the human ovary contains not less than 35,000 ova. As puberty ap- 
proaches, the distinction between the peripheral and central portion of 
the stroma becomes gradually less marked. Some of the vesicles enlarge, 
and, according to Schrcin, retreat in the first instance towards the centre 
of the ovary. When puberty is attained, a certain number of them en- 
laroje still further, and those Avhich have attained the orreatest size 
approach the surface. A few of them are from ^'^th to Jfch of an inch in 
diameter, or even more ; but the great majority remain much smaller. 
Their number is also greatly diminished as compared Avith those existing 
in the ovaries of children, so that we may assume that a large proportion 
is absorbed. The ova, which are contained within these Graafian vesicles, 
occupy in the case of the more developed vesicles a small space only, the 
rest of the vesicle being filled with fluid. Before puberty, the ovaries 
are smooth on the surface, but they subsequently become scarred, 
wrinkled, and furrowed, in consequence of the share which they take — 
as we shall see immediately — in the phenomena of ovulation. 

The Graafian vesicle is usually described as consisting of two coats 
and a granular epithelial layer, three special coverings in all ; but, in 
point of fact, there does not appear to be any distinct membrane lining 
the Graafian vesicle. This, indeed, is merely ovarian stroma in its finest 
form ; while, as regards the vascular layer usually described, its exist- 

' Transactions of the Royal Society of Edinburgli, 1875. 



76 



FEMALE ORGANS OF GENERATION. 



ence is more than doubtful, although, in its developed state, a network of 
bloodvessels runs near the surface of the vesicle. 

The Ovum, in the mature condition of the Graafian vesicle, lies near 
its surface, and is embedded in the memhrana granulosa ; a layer of 
peculiar nucleated and granular cells, which surrounds the whole of the 
interior of the vesicle, and is thickened at that part where the ovum is 
imbedded in it {proligerous disc of V. Baer). This is shown in the 
accompanying diagram. 

Fig. 38. 





Diagram showing the Layers of the Graafian Vesicle, and the contained Ovum. 

If the surface of the ovary be punctured, while a mature Graafian 
vesicle is projecting, and the contents of the latter pressed out, a small 

spherical body may be observed, if 
care be taken, covered with granu- 
lar matter in greater or less quan- 
tity. It is more opaque than the 
medium in which it is suspended, 
and is composed of the following 
parts: — 

a. A thick transparent envelope, 
which was called by Baer, the dis- 
tinguished discoverer of the ovum 
in the Mammalia, the .Zona pellu- 
cida. This is identical with the 
vitelline membrane, or membrane of the yolk in birds. It completely 
surrounds the ovum, and is to all appearance impervious. It presents at 
least no distinct aperture or micropyle such as is observed in some ani- 
mals, and has been by some supposed to exist in the human ovum. 

b. The Yolk. — The cavity inclosed by the zona pellucida is filled with 
a semifluid protoplasmic mass, which is viscid and faintly granular, and 
which readily escapes when the sac is ruptured. It can scarcely be 
described as a fluid, as it retains its spherical form after rupture of the 
sac, and may, according to Bischoif, be broken into segments. It has no 
investing membrane other than the zona pellucida. 

c. The Germinal Vesicle. — -In the middle of the yolk, in the earliest 
stage, and in contact, in adults, with some part of the periphery of the 
investing membrane, a little vesicle is found, apparently quite transparent 



Diagrammatic representation of the Ovujn, as it 
escapes from tlie Graafian Vesicle. 



STRUCTURE OF OVUM. 77 

and colorless, when seen in the more opaque medium in which it is sus- 
pended. This is the germinal vesicle — first described in the ova of birds 
by Purkinje, and discovered in the Mammalian ovum by Coste and by 
Wharton Jones. It is slightly oval, and surrounded by a very thin mem- 
brane. A more careful examination of it when removed from the yolk 
shows that it is not absolutely transparent, but contains a few scattered 
granules, and, in addition : — 

d. The G-erminal Spot of Wagner, which may be seen close to some 
point or other of the inner surface of the wall of the germinal vesicle. 
It is probably formed by the aggregation of cells and granules which give 
to it a greater opacity than characterizes the contents of the vesicle. 

Although it is generally understood that the ovum is to be found on 
the side of the vesicle next the surface of the ovary (Fig. 38), recent 
investigations have shown very clearly that this is by no means universal, 
and would almost seem to point to the conclusion that the contrary is the 
rule, and that, in the majority of Graafian vesicles, we are more likely 
to discover it on the side which lies towards the centre of the organ. 

The ova begin to be formed at a very early period, and are already to 
be found in great numbers in the superficial layer of the rudimentary 
stroma of the human ovary as early as the fourth month of intra-uterine 
life. Bat their first origin is even at an earlier period. The germinal 
vesicle is the part of the ovum first observed, and it appears to be formed 
by involution from the superficial layer of germinal cells. One or more 
of these cells, becoming larger than the rest, sink into the stroma and 
soon become surrounded by a single layer of nucleated cells. This con- 
stitutes the commencement of the membrana granulosa, and represents 
therefore the Graafian vesicle. As development proceeds, a small quan- 
tity of protoplasmic yolk surrounds the germinal vesicle, and the cells of 
the membrana granulosa increase in number and assume more of the 
appearance of a cellular lining. The cells accumulate round the simple 
ovum so as to form the proligerous disk, and a space begins to be apparent 
between this and the rest of the membrana granulosa, within which the 
fluid of the vesicle afterwards accumulates. The ovum grows by the 
increase of the yolk round the germinal vesicle, the protoplasm becoming 
granular; and, finally, the yolk and germinal vesicle are inclosed by the 
external firm vesicular membra,ne, known as the zona pellucida. 

These, then, are the parts of which the mature ovum, prior to impreg- 
nation, consists. On the approach of puberty, as has been seen, several 
Graafian vesicles, each containing an ovum, approach the surface of the 
ovary. As they increase in size, they form little projections beneath the 
investing membrane. In those animals where 
several ova are simultaneously fecundated — as 
in the sow (Fig. 40) — there may be observed 
on the surface of the ovary a number of little 
cystic growths ; but, in the human species, 
where the fecundation of more than one ovum 
at a time is exceptional, the Graafian vesicles, 
as a rule, come to maturity one by one. 

The changes which take place durino; matura- 

-I ^^ ^ n ,1 1 1 . 1 Development of Graafiau 

tion and discharge of the ova, and which are vesicies iu tiie sow. 




78 FEMALE ORGANS OF GENERATION. 

associated with the " rut" in many of the lower Mammalia, and with men- 
struation in women, constitute the phenomena of Ovulation. These 
changes are manifested, not only in the Graafian vesicle, but also in all 
the component parts of the internal generative system. 

It has already been observed that the development of the Graafian 
vesicle is due, in a great measure, to the increase in its fluid contents. 
While this is taking place, the vascularity is notably increased, not only 
in the vesicle itself, but in the contiguous portion of the ovary, and, in 
some degree, throughout the whole of the organ. The walls of the 
follicles become thickened, except at the part wdiere rupture is about to 
take place, and a certain amount of blood is said to be effused into the 
cavity. This has frequently been observed (although even that has been 
disputed) in the sac of ruptured follicles ; but the researches of Pouchet — 
whose views are confirmed by Farre — seem to show that an actual san- 
guineous discharge takes place into the follicle, at a period prior to its 
rupture. According to Pouchet, the efi"ect of this discharge is, mechani- 
cally, to force the ovum towards that part of the ovisac which is next the 
surface — it being, before this, generally found on the deep or distal side. 

An increased vascularity is now observed, externally, over the salient 
portion of the vesicle, and the tissues become, about the centre of the 
projection, more and more thinned, until, at last, they yield — the ovum 
then escaping by a process analogous to dehiscence. The rupture takes 
place in a small spot where the bloodvessels previously are w^anting. 
This is similar to the larger band of non-vascular tissue which exists in 
the ovicapsules of birds. Towards this non-vascular spot the neighboring 
vessels converge in considerable numbers, causing the appearance we 
have just referred to. Assuming the theories above mentioned to be 
correct, the bursting of the vesicle is due, not merely to an augmentation 
of its fluid contents, but to a thickening of its internal layer, w^hich be- 
comes at the same time irregidar in outline and yellowish in color ; and 
also to an effusion of blood, which has been termed the menstruation of 
the follicles. 

This evolution of the ovum is accompanied by important changes in 
various parts besides the ovary. In so far as the uterus is concerned, 
these changes will come to be considered under Menstruation. At pre- 
sent, it need only be observed that the whole of the internal genital 
organs become engorged. The Fallopian tube loses its pale color inter- 
nally, and often becomes of a violet hue from extreme congestion. This 
is more marked towards the fimbriated extremity, which completely em- 
braces that portion of the ovary where the mature vesicle is about to 
give way. The ovum is thus received into the Fallopian tube, but the 
rupture which admits of the dehiscence does not terminate the series of 
changes of which the ovary is the seat. 

Before attempting a description of these changes, how'ever, we must 
consider for a moment the conditions under w^hich rupture of the Graafian 
vesicle occurs, and the laws which determine this rupture. 

The celebrated experiments of Bischolf, as detailed in his well known 
work,^ have supplied most of the facts upon which, even at the present 

' Beweis der vender Begattung unabhangigen periodischen Reifiing mid Loslosniig 
der Eier, etc., 1844. 



PHENOMENA OF OVULATION. 79 

day, the conclusions of physiologists on this subject are based. From 
these, and from the corroborative results obtained by subsequent observ- 
ers, it is clear that ova may in the Mammalia, as in animals lower in the 
scale, be discharged from the ovary independently of sexual intercourse, 
or of any kind of influence from the male.^ In other words, sexual con- 
tact or excitement is not, as the earlier observers, down to Barry, 
believed, the one essential determining cause of the discharge of ova. 
From experiments on rabbits, which were conducted by Coste, it seems, 
however, more than probable that sexual congress may precipitate a rup- 
ture which, but for the excitement, would have been delayed. The 
immediate cause which leads to a rupture is thus somewhat obscure, but 
we recognize the fact that the occurrence is intimately associated with 
the maturation of the ovum, of which, in women, the periodic menstrual 
flow is the external manifestation. 

We have already seen that the internal layer of the Graafian vesicle 
presents a yellow color previous to its rupture, becomes wavy in outline, 
and is very considerably thicker. This change of color has been shown 
by Farre to be due to the presence of very minute oil granules, which 
give to the structure a yellow hue — hence the name given to the follicle 
during the period of decline — the Corpus Luteum. After rupture, a 
laceration, fissure, or scar, marks, on the surface of the ovary, the spot 
whence the ovum escaped, and a longitudinal section, made through the 
ovary in this situation, will generally bring the yellow body into view. 
At first, its distinguishing characteristics are but faintly shown ; and it 
is this fact which caused Raciborski to assert that the corpus luteum was 
not found before rupture. Undoubtedly, however, the first stage of its 
formation is while the ovum is still within the vesicle ; but it is only after 
rupture that the change in color becomes quite distinct — a change which 
Raciborski supposed to be due to an absorption of coloring matter from 
the blood-clot which fills the cavity. Whether it is due in part to this, 
or wholly to a further development of oil granules in the internal layer, 
as Coste supposed, the result is the yellow tint, whicli may be recognized 
from without, or, more distinctly, on section. If the laceration has pro- 
duced an opening of sufficient size, the clot which occupies the cavity 
may escape along with the ovum; but, if not, it is retained and absorbed. 
The folding of the internal layer now becomes much more distinct, so 
that the internal surface of the vesicle resembles cerebral convolutions 
on a minute scale. xVccording to Coste, this plication is due in great 
measure to retraction of the external coat, but this does not seem by any 
means clear, seeing that the convolutions become quite as distinct in 
those cases where the diameter of the whole vesicle is not diminished. It 
is much more likely that the plication is mainly due to the rapid increase 
in the cells of the membrane, which, being confined within a limited 
space, is thus necessarily thrown into folds. In every case, the cavity 
of the vesicle becomes rapidly encroached upon, the furrows between the 
convolutions become deeper, and the result is that the follicle now pre- 
sents, in a section, a stellated appearance, which is more or less marked 
according to the stage at which the corpus luteum has arrived. The 

1 See Raciborski " De la ponte periodiqne chez la femme et les Mammiferes." 1844. 



80 



FEMALE ORGANS OF GENERATION. 



various changes above alluded to are shown in Fig. 41, taken from 
Coste's Atlas, which represents an actual dissection, made at the Morgue, 
of the ovary of a young woman who had committed suicide towards the 



Fiff. 41. 




Ovai-y Dissected, to show the structure of the Graafian Vesicle at various stages. (Coste.) 



" 1. The vesicle to the left in the figui-e is intended to demonstrate the following pecu- 
liarities : — 

gg. The granular membrane, which covers the whole internal surface of the 
Grraafian vesicle. 
A thickened portion of this — granular disk — showing : — 

c. The Ovum surrounded by the cells of the disk, and situated, as is usual, im- 
mediately before rupture, on the side next the peritoneum. 
I i. Internal layer of the Graafian vesicle, showing a rich vascular network, not 
only on the flaps which are turned back, but also in the interior of the vesi- 
cle, through the granular membrane. 
ee. External (vascular) layer, vascular like the former. 

2. The open Graafian vesicle in the centre of the figure has broken spontaneously 
at the point v, and has allowed its ovum to escape. The nipple-shaped part of the 
granular membrane, in which the ovum was imbedded, has escaped along with it. 

g. Layer of granular membrane, which has not been dragged out with the ovum. 

i. Internal layer of the Graafian vesicle, forming numerous folds, which are the 
earliest of the modifications through which this layer passes in the forma- 
tion of the Corpus Luteum. 

e. External layer of the Graafian vesicle, retracted {sic Coste) on the former. 

3. The third Graafian vesicle, to the right, has been artificially pierced to show how 
the ovum, while escaping, drags with it that portion of the granular membrane in 
which it is lodged. 

g. Portion of the granular membrane, escaping by the opening made in the 

Graafian vesicle. 
ce. Ovum lodged in the thickened nipple-like projection of this membrane." 



THE CORPUS LUTEUM. 



81 



Fis. 42. 



end of a menstrual period. It must here be noted, however, that the 
most recent observations have failed to demonstrate the layers of the 
Graafian vesicle which Coste has so distinctly indicated. 

The ovary is partly dissected, to show the situation of the ova ; and 
also the structure of the Graafian vesicles, and the changes which they 
undergo after rupture. Most of the vesicles are turgid, tending to pro- 
trude, and indicated by the network of 
vessels on their walls. Three of them 
are open. 

Coste denies the presence, as a rule, 
of a blood- clot within the Graafian vesi- 
cle. He asserts that the vesicle, after 
rupture, becomes filled with a gelatin- 
ous matter, which is slightly tinged with 
the coloring matter of the blood. This 
he shows in Fig. 42, where the ovary 
is divided in its whole length to exhibit 
the organization of the corpus luteum. 
The preparation was taken from a woman, 
the mother of several children, who died ^ 
from poison a few days after menstrua- 
tion. The body was exhumed and ex- 
amined a week after death. No ovum 
was found in the uterus, nor in the Fal- 
lopian tube. An open corpus luteum, 
of considerable size, is here shown. ^, , .- .v, r. t . ,n . 

' structure oi the Corpus Luteum. (Coste.) 

" a. Internal layer of the Graafian vesicle, plicated and having commenced that 
hypertrophy which converts it into corpus luteum. 

h. Plastic semi-transparent matter, which occupies the centre of the corpus luteum, 
adheres intimately to the internal surface of the convolutions, and moulds itself upon 
them. To the right, this matter is left in its place ; on the left it has been detached, 
to show the subjacent convolutions and the impression which they leave upon it. 

c. An old corpus luteum, from a preceding menstruation, — probably the one before 
last. 

Graafian vesicles, — some intact, others open, and in various stages of development, 
are seen in other parts of the ovary." 

The description given, up to this point, applies to all corpora lutea, 
whether associated Avith pregnancy or not. It is therefore scarcely 
necessary to add that Haller was in error when he stated that " the 
corpus luteum is the effect of pregnancy alone." The demonstration of 
this error caused many hastily to assume that the corpus luteum was, 
under no circumstances, a sign of pregnancy, and w^as, in consequence, 
of no medico-legal value — an unfortunate mistake, which has been pro- 
ductive of much confusion, as there certainly are points of difference 
which enable us, with care, to distinguish between the two varieties. 

The corpus luteum which is found when there has been no impregna- 
tion, runs something like the following course from the point at which we 
left it. It shrinks rapidly, the retractility of the outer coat being 
apparently the chief agent in its contraction. The contiguous surfaces 
of the convolutions become pressed together, and their free surfaces 
gradually approach across the cavity, so as rapidly to cause its oblitera- 
6 





82 FEMALE ORGANS OF GENERATION. 

tion. The vascularity of the vesicle, and of the stroma of the ovary, 
becomes notably diminished, the ovisac loses its yellow color, and be- 
comes white — all these changes occurring in 
Z^^' ^^l>-_ about twenty-five or thirty days, so that, on 

the approach of another menstrual period, the 
cavity is reduced to a comparatively small size. 
At this stage, its appearance, as represented in 
Fig. 43, a, is very characteristic, the rays 
which proceed outwards from the central cavity 
showing the point of junction of the convolutions. 
Several other vesicles are shown, of the ordinary 
size before enlargement. From this stage, the 
stellate remains of the vesicles gradually dimin- 
ish in size, and retreat towards the centre of 

The Corpus Luteum of simple ,1 , , • 1 , ,1 ,•! , i , 

Ovulation. ^^^ stroma, to give place to others, until at last 

they are obliterated. Sometimes, they soften 
so rapidly, that they are completely re-absorbed before the folds of the 
internal layer have actually come in contact or contracted adhesions. 

Widely different is the state of matters where the ovum has been im- 
pregnated. In this case, the functional activity of the uterus is, in a 
measure, shared by the ovaries, and manifests itself in an increased vas- 
cularity, which, instead of disappearing, as at tlie end of a menstrual 
period, is maintained, more or less, during the whole course of the preg- 
nancy. It is, probably, in consequence of this that the corpus luteum of 
pregnancy goes through a series of transformations, so much more 
elaborate, and extending over a period the duration of which is so much 
longer. Taking the duration of an unimpregnated follicle as about two 
months to complete obliteration, the corpus luteum which accompanies 
pregnancy may be said to last usuallj^ for thirteen or fourteen months, 
while traces of it may be found at a still later period. 

Such an history involves the idea of special structure and modified 
development, and this a study of the facts amply corroborates. When 
pregnancy succeeds or accompanies the phenomena of ovulation, the 
earlier changes are the same as those already described ; but instead of 
softening and rapidly shrinking, as in the former case, the inner coat, or 
ovisac, continues to develop in thickness, and deepens in color, in conse- 
quence of an increase in the number of oil granules in its substance. 
There does not seem, in the first instance at least, to be any contraction 
whatever of the external membrane. On the contrary, there is some 
reason to believe that, at this stage, it often yields, so as to admit of an 
increase in the entire diameter of the vesicle, and, indeed, if we admit 
Coste's description to be correct, when he describes the corpus luteum of 
pregnancy to be " as large as the ovary itself," this can only be 
accounted for in the manner described. The size of the ruptured follicle 
varies considerably, but it often occupies, during the first four months, a 
fourth, a third, or a half of the entire ovary. During the period imme- 
diately succeeding impregnation, rapid hypertrophy of the inner coat 
goes on, and it becomes folded together into convolutions as before. The 
material being abundantly supplied, while the development still continues, 
causes the convolutions to be firmly pressed together, while their free 



THE CORPUS LUTEUM. 



83 



surface encroaches upon the cavity. At the end of two months, the 
condensation of the hypertrophied tissue of the ovisac will be found to 
have imparted to the follicle a considerable amount of solidity, which is 
quite obvious when it is pressed by the finger. Bloodvessels run through 
it, from the circumference towards the centre, marking, probably, the 
situation of the original folds. These latter are no longer distinct, and 
are so compressed laterally that the layer has now the appearance of a 
very thick yellow coat surrounding the diminished cavity, which is up to 
this time, according to Montgomery, usually circular in form, as shown 
in Fig. 44. A cavity, as here represented, is, however, exceptional. 

The blood-clot which originally occupied the cavity, or, if w^e choose 
to adopt the view of Coste, the tinged lymph which is effused after rup- 
ture, undergoes certain metamorphoses, which ultimately result in the 
formation of a milk-white coat which lines the cavity, taking the place, 
as it were, of the original granular membrane. This membrane, which 
is also shown in Fig. 44, is fibrous in structure, and extremely tough. 



Fiff. 44. 



Fi^. 45. 



Fi-. 46. 






Corpus Luteum in the Third 
Month of Pregnancy. (Mont- 
gomery.) 



Corpus Luteum at the Sixth 
Month of Pregnancy. (Mont- 
gomery.) 



Corpus Luteum at the Period 
of Delivery. 



Occasionally, the cavity is obliterated at the fourth month, but generally 
it will still be found perfectly distinct, although much reduced in size, up 
to the sixth month of pregnancy (Fig. 45). The walls continue gradually 
to^ approach nearer to each other, the Avhite lining membrane become's 
thinner, and folded into plaits, which, radiating outwards, are seen to 
intermingle with the yellow color of the ovisac. The outer boundary of 
the vesicle now becomes irregular in outline, and complete obliteration of 
the cavity ensues, a white stellated cicatrix in the midst of the yellow 
mass marking where its walls came into contact. This is shown in Fig. 
46, the original drawing of wdnch was taken by Montgomery from a 
woman who had died of inflammation of the uterus two days after mature 
delivery. Up to this time, and often for some wee\s afterwards, 
numerous vessels radiate through the corpus luteum, as may be proved 
by injection. This vascularity is now markedly diminished, while, at 
the same time, the characteristic yellow color becomes fainter in hue. It 



84 FEMALE OEGANS OF GENERATION. 

is often not till four or five months have elapsed that all trace of the 
corpus luteum has disappeared, a trace of the tough white membrane 
being then, it may be, still indicated by a very faint star-like scar in the 
stroma of the ovary. 

As the facts above set forth are of some medico-legal, as well as ob- 
stetric, importance, they may be briefly summarized as follows : — 

What is called the Corpus Luteum is due to a deposit of yellow fatty 
matter in, and hypertrophy of, the internal layer of the Graafian vesicle 
(ovisac). 

The formation of a corpus luteum always succeeds the rupture of a 
Graafian vesicle. 

Up to a certain point the changes in the Graafian vesicle are uniform, 
and have no relation to pregnancy. The corpus luteum of pregnancy 
may, however, be distinguished in its subsequent course, by its higher 
development and longer duration, its hardness, its vascularity, and, at 
a later stage, by the formation of the white lining membrane, and large 
central stellate cicatrix. 

The presence in the ovary of a corpus luteum is no evidence of preg- 
nancy, unless the characteristics last indicated are distinct and unequivocal 
— under which circumstances it is a certain sign. 

With reference to the above conclusions, it may be remarked that 
much confusion has arisen from the employment loosely of the terms 
" true" and " false," as applied to the corpus luteum, in so far as they 
are assumed to imply «b distinction, which proves or disproves the occur- 
rence of pregnancy. '' There is as little reason," says Farre, with justi- 
fiable emphasis, " for the use of the last term as there would be for de- 
nominating a child a false man These terms actually represent 

the same body, only in different stages of growth or decay." 

During the whole of the child-bearing period of a w^oman's life, the 
ripening and dehiscence of the Graafian vesicles are of periodic occur- 
rence. In those animals in w^hich plural births are the rule, several 
vesicles ripen and discharge their contents at, or near, the same time ; 
but in man this is exceptional, and we thus find that one vesicle only, 
as a rule, ripens at a time, bursts, discharges its contents, and rapidly 
shrinks as it retires towards the centre of the ovary ; to" give place, 
in a normal condition of the parts, to a constant succession of vesicles, 
which, one by one, run a similar course after discharging their ova. 
There is every reason to believe, further, that, during pregnancy and 
suckling, while the uterine functions are in abeyance, those also of the 
ovary are temporarily arrested, in so far as the development of new 
Graafian vesicles is concerned — the whole generative force being, as it 
were, turned into other channels. 

The numerous lacerations which, in consequence of repeated ruptures, 
take place on the surface of the ovary, leave, in the process of healing, 
corresponding cicatrices. On this account the smoothness of surface is 
soon lost, and it becomes more and more fissured and wrinkled, until, 
towards the end of the child-bearing epoch in a woman's life, the ovary 
is so irregular on the surface, as to warrant the comparison which 
Eaciborski has instituted between it and the kernel of a peach. After 
this, the organ becomes atrophied, and, like the uterus and other parts, 
is restored, in some measure, to the form which it presented in early life. 



MENSTRUATION AND CONCEPTION. 85 



CHAPTEE Y. 

MENSTRUATION AND CONCEPTION. 

The ^^RuV* of Mammalia: An alogij between this and Menstruation. — The first 
Menstrual Period: statistics of Duration of a ^^ period." — Quantity/ of the 
discharge. — Menstruation a hemorrhage. — Source of the Menses : various 
theories regarding. — PoucheVs Theory examined; is the Mucous Membrane 
shed? — Views of Kolliker, Coste, etc. — Duration of Child-bearing Epoch. — 
Cause of Menstruation.' — Conception. — Composition of the Semen. — Sperma- 
tozoa and their development. — The function of the Germinal Vesicle. — How 
does the Semen reach the Ovum ? 

There is, in the animal kingdom generally, a certain periodicity in the 
phenomena which attend the maturation of the Ovum. In the Mammalia, 
there always is a period of excitement, in which the whole generative 
apparatus more or less participates ; succeeded by a period of rest, of 
longer or shorter duration, according to the group or species, during 
which the organs involved are in a state of complete or comparative 
quiescence. The first marks the period at which the ovum is ready for 
impregnation ; during the latter, sexual coi:igress is, as a rule, ineffectual. 
This term of excitement, which is accompanied by general and local 
symptoms to be noticed presently, is called, in mammals lower in the 
scale than man, the rut or oestrus. 

There is not the slightest doubt that, in those animals, the escape of 
the ova from the ovary, and their passage down the Fallopian tube, are 
facts which coincide with the oestrus. The female then manifests an 
instinctive desire for copulation, and is generally said to be at this time 
" in season" or "in heat." The pudendum is congested and swollen, 
and the glands in this region pour out an abundant secretion, which, by 
its odor, attracts the male. This secretion, unless in those animals which 
come nearest to man in the scale, is very seldom even tinged with blood. 
In some cases, as was demonstrated by Bischoif in the case of the roe, 
the rut occurs only at intervals of a year, about the month of August. 
It is only at this period that the ovaries of the female contain ripe ova ; 
and, what is of even higher physiological interest, the semen of the male 
is elaborated then and then only, so that impregnation is doubly impossi- 
ble, except at a definite period, which leads to the birth of the young at 
that time of the year when they may be most easily reared. But, in 
many animals, the maturation and dehiscence of the ova occur with much 
greater frequency, and it is probable that food, domestication, and careful 
tending may modify the return of those periods. 

In women, during the period of ovulation, there are, as has already 
been shown, certain essential phenomena which are, so far, almost iden- 
tical with what we observe in other mammalia. But there is here a 



86 MENSTRUATION AND CONCEPTION. 

special phenomenon superadded, which is in fact the external manifesta- 
tion of what we know to be taking place internally. This consists in a 
discharge from the uterus of nearly pure blood, which lasts usually for 
several days. It is called the " catamenial" or "menstrual" discharge, 
as it occurs very constantly at intervals of a month ; the occurrence 
being, in its course, usually designated as Menstruation. 

A very warm discussion has been maintained for many years as to 
whether the " rut" and " menstruation" are to be held as analogous. 
Up to a certain point, the analogy is admitted by all ; but it must be 
conceded that, between the two, distinctions and even contrasts are 
found, on careful examination, to arise, which seem to challenge the 
truth of the assertion which many have made, that the phenomena are 
physiologically identical. Without expressing any confident opinion as 
to this qucestio vexata, we may here mention the chief points, in addition 
to the sanguineous discharge, in which they differ. Impregnation takes 
place during the excitement of the rut, w^hile as a general rule it occurs 
in women about a week after menstruation, during the period of rest. 
Again, there succeeds to the rut a period of sexual inappetence, when 
not only does the female refuse the male, but in some cases no semen is, 
as we have seen, secreted ; in the human species there is, strictly speak- 
ing, no period of inappetence, not even excepting the period of the men- 
strual discharge, so that at any time impregnation 7nai^ occur. Great as 
these differences undoubtedly are, and even if we admit that they destroy 
the identity of the acts, they are scarcely sufficient to warrant us in 
rejecting the analogy ; for, although the subject is still obscure, a more 
accurate knowledge of the time occupied by the descent of the human 
ovum ma}^ show that the above points of contrast are more apparent than 
real. 

Menstruation is familiarly termed by women the "courses," "monthly 
illness," or "period." It is not to be looked upon as an isolated act, 
but as one of the important series of phenomena which occur during 
ovulation; and as such it requires special and careful attention. Its 
first appearance is associated with the other signs of puberty. The ap- 
proach of this is indicated by an alteration in the form of the pelvis, and 
a consequent change in figure and gait ; by the growth of hair on the 
pubes, the rapid development of the mammse, the greater projection of 
the nipple, and the deeper color of the areola. These physical modifica- 
tions are generally associated with very characteristic moral changes. A 
frank romping manner gives place to one more timid and gentle, and the 
loud voice and ringing laughter of childhood is replaced by subdued 
tones and bashful reserve. A Graafian vesicle now for the first time 
comes to maturity, and projects on the surface of the ovary, which is 
embraced by the fimbriae of the Fallopian tube, while the whole of the 
organs, including the uterus, become highly congested, and the menstrual 
flow begins. 

According to Boerhaave, the first menstruation is accompanied with a 
certain amount of fever, as the result of the excitement of the genital 
organs. The girl complains of lassitude, hypogastric fulness, lumbar 
and sacral pains, slight itching and tumefaction of the external genitals, 
and a painful SAvelling of the mammae. Not unfrequently, hysteria, 



STATISTICS OF MENSTRUATION. 87 

chorea, and other nervous disorders, manifest themselves — generally in 
a mild form. After a few days a mucous discharge, more or less abun- 
dant, is observed ; this becomes tinged with blood, and after a time is 
found to be almost pure blood, to be again replaced by a tinted, and 
finally by a clear discharge, closely resembling that which at first showed 
itself. The previous symptoms disappear with the menses, which may 
have lasted a week ; and she is restored to perfect health, but with an 
indescribable something in manner and appearance which marks the 
transition into womanhood. Such symptoms as are above detailed, on 
the authority of Boerhaave, as accompanying a first menstruation, are 
generally slight in degree, the discharge often appearing during sleep, 
or at any other time, without anything whatever of the nature of pre- 
monitory symptoms. Very often, for a period or two, some of the same 
symptoms are experienced, at intervals of a month, without any flow of 
blood. These indicate preliminary or abortive attempts on the part of 
nature, — the Graafian vesicles being, probably, as yet, not perfectly 
mature ; but there is little reason to doubt, that the first maturation of a 
vesicle is, as a rule, coincident with the first menstrual discharge. 

The initiation of this period of a woman's life is believed to be hastened 
by hot climates, by residence in towns and the habits which are there 
contracted, and by constitutional vigor ; while cold temperatures, country 
residence, and a feeble and delicate temperament retard the act. In a 
certain number of cases, menstruation is postponed to a period of life 
much more advanced than usual. We read, for example, of a case in 
w^hich a woman who had married at twenty-seven, menstruated for the 
first time two months after her eioihth labor; and of another who had no 
discharge till after her second marriage, at the age of forty. Numerous 
cases of premature menstruation are also on record, where menstruation 
has actually appeared during infancy, and where the external appear- 
ances and sexual desires of maturity have been manifested at a very 
early age. Such cases are, of course, extremely rare; but of more fre- 
quent occurrence are those instances in which women become pregnant 
without ever having menstruated ; while it is quite a common thing for a 
woman who is nursing to become pregnant again before the menses have 
returned, such facts indicating, as Cazeaux observes, that menstruation 
plays a secondary part in tlie phenomena of ovulation. 

Putting such exceptional cases aside, as irregular and abnormal, w^e at 
once recognize the fact, that the time of a first menstruation varies 
greatly, according to climate, constitution, and the kind of life which is 
led. In so far as climate is concerned, the influence exercised by it, 
while quite marked, is by no means so inconsiderable as was once be- 
lieved, and may be represented by a period of three years at the furthest 
between the extremes, which we may suppose to exist in the Hindoo and 
the Esquimau. At one time, ideas were entertained on this subject 
which more correct observation has shown to be absurd, and to no one 
are we more indebted than to Mr. Roberton, of Manchester, for clearing 
away the errors which were long promulgated on these points. The fol- 
lowing Table, which shows the period of the first menstruation in 8983 
cases, is the result of a very careful analysis of the most reliable statis- 
tics which have been published in Europe on this subject. 



MENSTRUATION AND CONCEPTION. 



Age. 



Under 10 
10 to 11 



11 ' 

12 ' 

13 * 

14 ' 

15 ' 

16 ' 

17 ' 

18 ' 

19 ' 

20 ' 

21 ' 
Over 



12 
13 
14 

15 
16 
17 

18 
19 
20 
21 

22 
22 



Total, 



Eoberton, 
Lee, White- 
head, and 
Murphy. 



14 

64 

103 

278 

595 

1034 

1178 

1307 

714 

531 

213 

104 

18 

17 

6175 



France. 



Brier re de 

Boismout, 

Racibor^ki, 

Bouchacourt, 



16 
41 

138 

209 

258 

355 

411 

349 

287 

190 

102 

66 

31 

23 



2476 



Germany. 


Norway. 


Osiander. 


Faye. 


*3 


"4 


8 


4 


21 


13 


32 


14 


24 


20 


11 


13 


18 


13 


10 


6 


8 


8 


1 


3 


1 


2 


137 


100 



Russia. 



Lebrun. 



1 

15 

27 
35 
13 

6 
2 
1 



100 



Total. 



30 

105 

241 

494 

865 

1424 

1650 

1727 

1060 

765 

337 

188 

54 

43 



8983 



Some idea is here given of the variation in the different countries of 
Europe, and we notice the very small proportion of cases in which men- 
struation first appears under ten or over twenty -two years. The period, 
as will be observed, varies very considerably, about the age of sixteen 
being the time at which it most frequently shows itself in this country. 
At any age, however, between twelve and twenty, the function may be 
established, without any peculiarity whatever in the attendant symptoms 
or deterioration of the general health ; but, if beyond these limits, it may 
be looked upon as exceptional and irregular, although, even then, as in 
the cases alluded to, the health may in no way suffer. 

Once established, the menses should return with periodic regularity 
during the whole child-bearing epoch. The recurrence of the discharge 
is always attended with local, and generally with constitutional symp- 
toms. The latter are identical with those which accompany the first 
menstruation, only less in degree, and constitute what has been termed 
the menstrual molimen. The only circumstances which normally arrest 
this function of the uterus are pregnancy and lactation, during which the 
ovarian and uterine functions are generally in complete abeyance. If, 
under other circumstances, it should disappear during the child-bearing 
epoch, it is regarded as an indication of some morbid condition, usually 
constitutional, which declares itself as a rule by the presence of other 
symptoms. It may last from one to eight days, eight being, according 
to Brierre de Boismont, the most common, and, strange to say, seven the 
least so. The follo^ving is, according to the same observer, the duration 
of days arranged in the order of frequency in which each day is se- 
lected : — 

8:3:4: 2:5:1:6:10:7.^ 



De la Menstruation : par A. Brierre de Boismont. Paris, 1842. 



QUANTITY OF THE DISCHARGE. 89 

The catamenial period and interval together occupy a period of a 
month of four weeks, or twenty-eight days. This is the rhythm of the 
act in such a large proportion of cases, that we may set it down as the 
rule ; but it is a rule to which we find constant exceptions, a few days 
more or less than the limit here mentioned being of frequent occurrence, 
much greater irregularities, indeed, being quite compatible with perfect 
health. It is by no means rare to find a woman who menstruates once 
in six Aveeks or once in a fortnight, without any inconvenience whatever. 
In all cases, it is the continuance of the flow which mainly determines 
the duration of the interval or intermenstrual period. In some, and 
under the influence of morbid conditions, a leucorrhoeal discharge takes 
the place of the ordinary menstrual flow ; and, in others, the molimen is 
relieved by a discharge of a hemorrhagic nature from some other surface. 
Both of these conditions, although essentially pathological, are, never- 
theless, in not a few instances, beneficial in their action. 

The amount of the discharge is very variable, even in the same woman, 
and very diS"erent opinions have been formed as to what is to be con- 
sidered a normal quantity over the whole period. The obvious difficul- 
,ties in the way of such an investigation have hitherto prevented anything 
like a reliable estimate. That of Hippocrates, which we have on the 
authority of Galen, assumes eighteen ounces to be lost at each period, 
but this has not been confirmed, even approximately, by any modern ob- 
server. Meigs put it down at four to six ounces, and Farre at two to 
three ; and there can be no doubt that these figures give a more accurate 
idea, and that Farre is probably correct when he says " that a discharge, 
amounting to six or more ounces in the aggregate, will generally produce 
for the time sensible efi'ects upon the constitution, such as general pallor, 
and some feebleness of the muscular system." 

In regard to the nature and influence of the menstrual discharge, very 
incorrect and even fabulous opinions were entertained. Pliny assures 
us that the presence of a menstruating woman blights vegetation, turns 
wine sour, and produces a number of other and similar eftects ; and in 
some districts, even at the present day, traces of this superstition are to 
be found. The peculiar odor which was described by De Graaf, and 
which has been compared by some French physiologists to that of the 
marigold, is a very usual characteristic of the discharge ; but it is scarcely 
necessary to add that, in the absence of any morbid condition, neither 
this nor any other quality of the discharge can produce deleterious results. 
During the height of the period, it is composed, as the researches of 
Donne, Pouchet, Letheby, and others, have abundantly proved, almost 
entirely of pure blood, mixed with a certain quantity of mucus. During 
the periods of invasion and decline, the mucus predominates, the color 
being in direct proportion to the number of blood corpuscles, which are 
seen by the microscope, mixed with epithelial scales and with mucous 
corpuscles from the cervix. 

There is one striking peculiarity which serves to distinguish this from 
ordinary hemorrhagic discharges — its want of coagulability. This was 
at one time supposed to be of itself sufficient evidence that it was not 
blood, or was blood deprived of fibrine ; but no doubt now remains that 
the arrest of coagulation depends upon the mixture of the acid secretion 



yU MENSTRUATION AND CONCEPTION. 

of the vagina with the still fluid blood as it escapes from the os, which 
not only maintains the fibrine in solution, but also renders it difficult of 
chemical detection. When the quantity is excessive, constituting the 
affection known as menorrhagia, nothing is more common than to find 
clots discharged, the blood being then so far in excess as to neutralize 
the acid in the vagina. And, besides, it has been proved that if the 
blood be collected as it escapes from the os, and before it mixes with the 
mucus, it is coagulable and alkaline in reaction. These facts suffice to 
prove that the discharge is a hemorrhage. 

Source of the Menstrual Discliar ge. — There are few subjects in physi- 
ology which have given rise to more discussion than this. Some observers 
have seen blood oozing from the surface of the vaginal mucous membrane, 
while others have traced it to the os and cervix uteri ; and on isolated 
observations such as these, theories on the subject have been founded. 
Admitting the facts upon which these theories have an unsubstantial basis, 
we recognize in them nothing more than examples of vicarious menstrua- 
tion, a term Avhich has been applied to those cases in which the menstrual 
molimen is relieved by a discharge through an unwonted channel. That 
the menstrual discharge has its true source in the mucous membrane 
w^hich lines the cavity of the uterus is a fact which admits of no doubt, 
and has been proved to demonstration, by examination of the uteri of 
women who have died during a period; by accumulation of blood within 
the cavity in cases of atresia of the cervix or of the vagina ; anrl, finally , 
by the examination of cases of chronic inversion of the uterus, which 
offer peculiar facilities for the study of the subject. 

In our view of ovulation, those of the essential phenomena of the pro- 
cess which have their seat in the uterus and its lining membrane, were 
left for consideration at this place. In point of fact, we may assume that 
menstruation itself is essentially one of these phenomena, which are 
mutually dependent on each other. Along with the enlargement of the 
ovary and Fallopian tubes already described, a very considerable enlarge- 
ment, involving an increase in weight,, takes place in the uterus. Its 
vascular apparatus becomes developed and injected in an unusual degree. 
This is especially marked in the case of the mucous membrane, on the 
surface of which, under the epithelium, the vascular network already de- 
scribed becomes very distinct where the vessels surround the orifices of 
the tubular glands. The glands themselves are also visibly enlarged, and 
any difficulty which may arise in demonstrating them while the uterus is 
at rest, now no longer exists. The membrane becomes increased in thick- 
ness, its color is deepened, and the temperature of the whole womb is 
raised. The result of these changes is that the membrane becomes 
hypertrophied to such an extent that it is thrown into convolutions, which 
are soft, pressed together, and project into the cavity so as to fill it com- 
pletely, its walls being thus no longer smooth but wrinkled. (Fig. 47.) 
M. Coste, whose conclusions are based upon no inconsiderable number of 
such observations, says that, save as a pathological product, no such 
pseudo-membranous exudation exists, as has been described by physiolo- 
gists of repute. 

A closer examination of the surface shows that, at this period, it is 
dotted over with minute specks, which a low magnifying power proves to 



SOURCE OF THE MENSTRUAL DISCHARGE. 



91 



FiK. 4^ 




Tumefactioa of the Uteriae Mucous Membrau( 
during Menstruation. (After Coste.) 



be small drops of blood occupying the orifices of the tubular glands, from 
which they may be dislodged by gentle compression of the avails. This, 
however, does not terminate the 
ultimate source of the hemor- 
rhagic flow, and it is around this 
part of the subject that the 
greatest difficulties have arisen. 

That it is not a secretion, in 
the proper acceptation of the 
term, as was once believed, is a 
postulate which the analysis of 
the discbarge enables us to affirm. 
We need not therefore address 
ourselves to the refutation of an 
exploded theory. The view en- 
tertained by Coste is that it is a 
transudation through the walls of 
capillary vessels, chiefly venous, 
or, in other words (if we do not 
misunderstand him), that a con- 
siderable hemorrhage takes place 
in this manner without any breach 
whatever in the walls even of 
the smallest vessels, a conclusion 

which all physiological analogy forbids us to accept. That there may be 
permanent vascular orifices through which the blood escapes during the 
menstrual period is an idea which has found favor in the eyes of some 
eminent physiologists, among others Dr. Farre. Nor is this so fanciful 
a view as one might be disposed at first to consider it. If there are per- 
manent orifices, it may indeed be asked, why is there not continuous 
hemorrhage ? And in reply, it may be assumed, hypothetically of course, 
that these orifices are, during the inter-menstrual period, closed by the 
contractility of the tissues which surround them ; but that the increased 
vascularity, tumefaction, and relaxation of all these parts, which coincide 
so constantly with the other phenomena of ovulation, admit of a welling 
forth of pure blood through apertures which now, under the special cir- 
cumstances, become patent, and which, the height of the period having 
passed, forthwith commence to close, to open afresh on the approach of 
the next menstruation. 

The theory, however, which perhaps of all others has attracted in 
recent times the greatest amount of attention, is that which is associated 
. chiefly with the name of M. Pouchet, and to this theory some of the 
ablest of our Eng-lish writers have o;iven their adhesion. Pouchet — if we 
mistake not — supposed that the whole, or at least the greater part of the 
mucous membrane (not the epithelium merely) is shed at each catamenial 
period ; and that its separation from the subjacent tissues involves the 
rupture of vessels, whence the menstrual flow. This, however, would in- 
volve a very different appearance of the internal surface of the uterus, 
from that which has been above described as occurring at this time, and 
which we believe to be substantially correct. A separation of a mem- 



92 MENSTRUATION AND CONCEPTION. 

brane so thick and so important would, in fact, be capable of obvious 
anatomical demonstration ;, and if it could be so demonstrated, we would 
at once have, in the trunks of the vessels which must of necessity be rup- 
tured, the source, clear and unequivocal, which we are endeavoring to 
trace. The separation of the mucous membrane of the uterus, under the 
name of decidua, which occurs in women at the moment of delivery ; and 
the occasional occurrence of what is known as membranous dysmenorrhoea, 
when, in certain morbid conditions, the whole membrane is actually ex- 
foliated, and shed either piecemeal or entire, are facts which have seemed 
to M. Pouchet sufficient to establish an analogy, on which, mainly, his 
theory is based. The mucous membrane, he says, is deciduous not 
merely at the termination of pregnancy, or as a consequence of an ex- 
ceptional morbid action, but at each menstrual period. Ko such separa- 
tion takes place in the lower animals, and in this distinction we find 
revealed at once the source of the menstrual discharge, and the reason 
why, in the human species, hemorrhage is superadded to the ordinary 
phenomena of " rut." Ingenious as this theory may be, and interesting 
as the facts undoubtedly are which its promoter has brought to bear 
upon it, it is one, we think, which requires closer investigation. 

If M. Pouchet could show us the exfoliated membrane, and the raw, 
bleeding surface which its removal necessarily involves, as he might do 
in membranous dysmenorrhoea, or in women Avho have died shortly after 
delivery, his theory would be established, and the question forever set 
at rest. But in this he has scarcely succeeded. Opportunities of exam- 
ining the bodies of women who die during a menstrual period are, no 
doubt, rare ; but a sufficient number of such examinations have been 
made by Coste, and, more recently, by Kundrat and Engelman, to show 
what is the usual condition of the parts. In a certain number of cases, 
no doubt, something approaching to complete exfoliation does occur, but 
even Pouchet himself is forced to admit that these cases are exceptional. 
Ilis ultimate conclusion seems to be that the membrane desquamates, not 
during menstruation, but in the interval. This, however, abandons all 
the advantage Avhich he gained from the analogy which he so ingeniously 
established. For there can be no comparison between a desquamation 
occurring when the functional activity of the womb is in abeyance, and 
one which is uniformly associated with its highest functions ; although 
an analogy might fairly enough have been traced between the birth of 
the decidua, in the final act of parturition, and the shedding of the same 
membrane in connection with a process which is held to be, up to a cer- 
tain point, preparatory to the reception and development of the ovum. 

The separation of the membrane from the subjacent structures would 
certainly, if occurring during menstruation, account satisfactorily for 
the discharge ; but, even if it were established that an inter-menstrual 
exfoliation did occur, this would, in no sense whatever, account for the 
periodical phenomena of menstruation. Dr. Tyler Smith states, that, 
having had several opportunities of examining the uteri of women who 
had died during menstruation, he found that the appearances presented 
were similar to those which are observed after abortion. " In each of 
those cases," he says, " I found the mucous membrane of the body of 
the uterus either in a state of dissolution, or entirely wanting." In one 



SOURCE OF THE MENSTRUAL DISCHARGE. 93 

case — of which he gives a drawing in his " Manual" — he found that 
" in the cervical canal the mucous membrane was perfect, but at the os 
uteri internum it ceased as abruptly as though it had been dissected 
away with a knife above this point. Blood was oozing at numerous 
points, from broken vessels in the submucous tissue." In a microscopic 
examination of this case, in which he was assisted by Dr. Handheld 
Jones, no traces of the epithelium or tubular glands could be found. 
Now, if Dr. Tyler Smith founds his belief in the exfoliation theory, on 
such cases as this, he goes much further than Pouchet himself, in 
attempting to prove, what that physiologist does not, that the separation 
of the membrane occurs during menstruation. Speaking with t-hat 
respect for his views to which such an eminent observer is entitled, w^e 
are inclined to assume that Dr. Tyler Smith was mistaken, and that the 
case was either a very exceptional one, or that he mistook shedding of 
the epithelium for separation of the entire membrane. 

We believe that, in all probability, the views of Kolliker, which have 
been recently, in some degree, confirmed by Robin, point to a more 
correct conclusion than any of the theories above stated. These dis- 
tinguished histologists believe, with Coste, that the mucous membrane 
becomes thickened during menstruation. Tliey hold, however, that the 
blood escapes from ruptured superficial capillaries, the epithelium cover- 
ing the mucous membrane being, in great part, thrown off. The interest- 
ing observations of Robin, as to the structure of the tubular glands, make 
it more than likely that a considerable portion of the discharge comes 
from these ; but that it comes from the surface of the membrane as well, 
and probably, to a trifling extent, from that of the Fallopian tubes, we 
may consider as certain. There can be little doubt, however, that a 
certain change does take place in the epithelium during menstruation. In- 
dependent observers have shown, for example, that, as during pregnancy, 
so also at this time, the epithelium is deprived of its vibratile cilia. Farre 
has occasionally observed, in an injected uterus, that the capillary ves- 
sels, which form so fine a network upon its inner surface, are '" denuded, 
and hanging forth in detached loops." Such observations, taken along 
with the fact that epithelial cells, and a certain amount of debris, are 
found mingled with the catamenial discharge, suffice, we think, to prove 
that, during menstruation, the flow of blood is from the mucous membrane 
of the cavity, and that certain changes in, and probable loss of, the epi- 
thelium, are associated with the flow. 

The view above expressed has received recent confirmation from the 
interesting observations of Kundrat, above referred to. As the result 
of microscopic researches in the case of Avomen who w^ere menstruating 
at the time of their death, he concludes that, a few days before the 
menstrual flow is established, a proliferation of the cells of the inter- 
glandular tissue takes place, by which that portion of the mucous mem- 
brane w^hich lies nearest the cavity becomes infiltrated with newly-formed 
round cells. When the capillary vessels rupture, these cells have already 
passed through a stage of cloudy swelling and fatty degeneration, and it 
is this superficial portion of the mucous membrane which is thrown off 
during the continuance of the discharge, and for some days after its 
cessation. To this extent, then, we hold it to be established that the 



94 MENSTRUATION AND CONCEPTION. 

mucous membrane of the uterus is shed at each menstrual period ; and 
that Pouchet's theory, as corrected by more modern research, is not so 
wide of the truth as it at first appears. 

The menstrual, or child-bearing epoch of a woman's life, lasts on an 
average from twenty-five to thirty years, ceasing most frequently between 
the ages of forty-five and fifty. So long as the woman enjoys perfect 
health, the appearance of the discharge should be at regular intervals, of 
which the normal duration is twenty-eight da^^s. Some women, however, 
as is well known, menstruate every three or every six weeks, and we are 
only justified, practically, in looking upon such cases as abnormal, when 
the-general symptoms are such as to call for interference. Irregularities 
occur, too, as we have already seen, frequently enough during the first 
months of menstruation ; and we find also that, as the catamenial climac- 
teric or change of life approaches, the cessation of the menstrual function 
does not occur abruptly, but after marked premonitory symptoms. At 
this period of her life, a woman becomes subject to many hysterical and 
other minor ailments, from which she may previously have enjoyed an 
entire immunity. A period may, possibly for the first time, pass with- 
out discharge. On the next occasion, an increased quantity seems as it 
were to compensate for the omission which nature had made. Intervals 
of longer duration may now succeed, intervals which bear no relation to 
former inter-menstrual periods until after a certain num.ber of fitful and 
capricious efforts on the part of the uterus to relieve itself as before, the 
catamenia finally cease ; the uterus becomes less in size, and the ovaries 
shrink so rapidly, that they become wrinkled on their external surface, 
so as to resemble, as Raciborski says, the kernel of a peach. As a rule, 
menstruation ceases during pregnancy and lactation ; but to this rule 
there are exceptions, as we occasionally meet with cases where women 
continue to have their periods for some time after conception, and not un- 
frequently, during lactation, menstruation goes on with perfect regularity. 
Any menstrual irregularity, however, occurring during the period of a 
woman's life which we are here considering, and independent of preg- 
nancy, is to be looked upon as an abnormal state which calls for treat- 
ment with the view to the maintenance of her health. These, and other 
menstrual disorders, constitute a class of diseases to the treatment of 
which the physician has constantly to address himself. 

The cause of menstruation is a question which has given rise to a great 
deal of useless discussion, and to not a few baseless theories. Without 
broadly asserting that the two phenomena stand to each other in the rela- 
tion of cause and effect, we are, in the present state of our knowledge, 
entitled to assume that the periodical discharge depends upon correspond- 
ing changes in the ovary, associated with the maturation of a Graafian 
vesicle. This is proved by the examination of the ovaries of women who 
have died during menstruation, when the appearances already described 
are generally to be found ; by the almost invariable cessation of menstrua- 
tion when the ovaries have been removed;^ and by the facts which a 

1 Percival Pott's well known and often quoted case, corroborated by similar obser- 
vations hy Cazeaux, Oldham, and others, was long held as conclusive evidence that 
menstruation in the absence of the ovaries was impossible. A sufficient number of 
cases have, however, been reported on good authority to show that, exceptionally, 
periodic sanguineous discharges may go on in the absence of the ovaries. 



THE SEMINAL FLUID. 95 

careful examination of the phenomena of the " rut" of the lower animals 
discloses. Why the act should recur at periods so regular and constant, 
is a question which we need scarcely attempt to answer. That, in one 
animal, a single Graafian vesicle should come to maturity each month, in 
another, a cluster ripen simultaneously, and, in a third, that evolution 
should occur at intervals of a year, are facts which display a marvellous 
accordance with the purposes of nature in regard to the propagation of 
species, but the}^ are facts, the ultimate cause of which will continue to 
baffle the speculation of the astutest intellects. 

Conception, Fecundation, and Impregnation, are terms all of which 
imply fruitful contact of the male and female elements, so that a new 
organism comes into existence. The fecundating principle which is con- 
tributed by the male begins to be secreted by the testes at the age of 
puberty, and is known as the semen or seminal fluid. At the time of 
sexual contact, the excitement of the erectile tissue is such, that, acting 
through the medium of a ganglionic centre, which is supposed to be 
situated in the lower portion of the spinal cord, it culminates in an 
orgasm, during which certain muscular fibres are called into a reflex and 
convulsive action. The semen is thus ejaculated with considerable force 
by the fibres of the vasa deferentia, and by the special muscles which 
surround the vesiculse seminales and the prostate gland, its regurgitation 
towards the bladder being prevented, according to Kobelt, by the tume- 
faction of the verumontanum which occurs during the period of erection. 
It is thus thrown for the most part into the upper part of the vagina, and 
over the os and vaginal portion of the cervix ; but it is well known to 
medical jurists that this, although highly favorable to impregnation, is 
not essential. On the contrary, there are perhaps few physicians of ex- 
perience who have not met with cases where women, believing themselves 
sqfe^ have permitted a certain amount of sexual contact without penetra- 
tion, and have thus become pregnant. All, in fact, that seems to be 
essential is contact of the seminal fluid with the pudendum, which is 
further proved by observations of pregnancy coincident with perfect 
hymen. 

The semen is a thick, glutinous, whitish fluid, albuminous, heavier than 
water, and emitting a peculiar odor. If subjected to examination by a 
considerable magnifying power, it is found to consist of a number of little, 
oval, flattened bodies, which in man are not more than g^Vo o^ ^^ i^^^^ 
in width, furnished with long filiform tails, which taper gradually to the 
finest point. A lashing undulating motion is imparted to these bodies, 
for a certain time, varying according to circumstances from several hours 
to several days, after death or ejaculation. This. brisk and constant 
movement, which has led Kolliker to compare them to ciliated cells, gave 
rise to the erroneous opinion that they were animalcules — hence the name 
which they still retain. Spermatozoa. Besides these bodies, there are 
observed certain minute round and granular masses, varying in number, 
but always fewer in ripe semen than the Spermatozoa themselves. These 
are what were originally termed by Wagner, " seminal granules," but 
which have been shown by his subsequent researches, and by those of 
Kolliker, Leuckart, etc., to be cells within which the Spermatozoa are 
developed, and are now termed vesicles of evolution. These again are 



96 



MENSTRUATION AND CONCEPTION 




Spermatozoa and Vesicles of Evolutioa 



generally found to be inclosed in groups of from three to seven within pa- 
rent cells (Fig. 48, 5 5), but each vesicle of evolution is destined for the 

development of a single spermatozoon, 
as is shown in a mature specimen at c. 
The individual spermatozoa escape there- 
after by rupture of the containing vesi- 
cle, and may now {a) exhibit their cha- 
racteristic movements. Sometimes rup- 
ture of the vesicles of evolution takes 
place without absorption of the parent 
cell, when the appearance produced is 
that shown at d^ where a bundle of 
spermatozoa is seen, their number cor- 
responding to that of the original vesi- 
cles. It is only, it may be observed, 
by careful examination of the semen in the testes, epididymis, and 
other portions of the tract, that these several stages may be traced. 
These elements of the semen are found to float in a limited quantity of 
clear perfectly homogeneous liquid. Direct experiment on the ova of the 
Amphibia has proved that it is in the spermatic particles and not in this 
fluid that the fecundating principle resides. If the spermatozoa are ab- 
sent, therefore, as in debility, disease, or old age, impregnation is im- 
possible, and it is their absence in the semen of hybrids that renders 
these animals sterile. 

The Ovum, at the stage at which we left it, was escaping, or about to 
escape, from a ripe Graafian follicle. It is then composed of the follow- 
ing parts (see Fig. 39, p. 76) : — 

a, Of a thick transparent membrane, which completely surrounds it, 
and exhibits no trace of vascularity— the zona pelliicida of Baer, or vitel- 
line membrane of Coste : 

5, Of a granular yolk contained in this vesicle : 
c, Of the germinal vesicle of Purkinje : 
c?. Of the germinal spot of Wagner. 

The Germinal Vesicle, as the period of dehiscence approaches, moves, 
as we have seen, towards the periphery of the yolk, both it, and the 
germinal spot within it, being so placed as to be as near as possible to 
the point where rupture is about to occur, as if to seek the fertilizing in- 
fluence of the male. Since Bischoif actually demonstrated the presence 
of spermatozoa on the ovaries of bitches and rabbits, in whom congress 
has been permitted at the proper period, few physiologists question the 
possibility of impregnation occurring while the ovum is yet in the ovary ; 
and, indeed, if true ovarian pregnancy is possible, — which some doubt, — 
it is only in this way that impregnation can, in these cases, occur. It 
has been generally assumed, however, that a rupture of the walls of the 
Graafian vesicle could alone permit of such impregnation ; but if we may 
so far judge from analogy, what has recently been divulged in reference 
to the penetration of the walls of bloodvessels by the white corpuscles of 
the blood, and their subsequent appearance as pus cells, we may at least 
admit the possibility that particles endowed Avith such mobility may pene- 
trate the attenuated walls of a Graafian vesicle, even before rupture. 



CONTACT OF OVUM WITH SPERMATOZOA. 97 

In the osseous fishes, and in some animals lower in the scale, it has 
been shown that a minute opening (inicropyle) exists in the zona pellu- 
cida, which has been supposed by Dr. Allen Thomson to facilitate the 
fecundation of ova possessed of very thick external coverings. No reason 
other than this exists for the belief, which some have entertained, that a 
similar aperture in the Mammalia facilitates the introduction of the sper- 
matozoa, but there are many reasons for believing that these latter do 
really penetrate the zona pellucida. 

The cessation of the characteristic movements of the spermatozoa marks 
the termination of the period during which their fertilizing influence may 
be exercised. The duration of the period will, therefore, obviously de- 
pend upon the circumstances under which the semen is placed. Its 
admixture, at the time of ejaculation, with the prostatic fluid and the 
secretion of Cowper's glands, and, subsequently, with the vaginal and 
uterine secretions, are obviously circumstances which tend to preserve 
the spermatozoa, by furnishing a medium in which they may freely float: 
an absence of these conditions would necessarily curtail their vitality. 
Although we may assume it as possible that impregnation may occur in 
the ovary, it by no means follows that it can occur nowhere else. But 
it is certain that the contact between the male and female elements must 
almost always take place, if not in the ovary, at some point between it 
and the upper third of the uterine cavity. Bischolf affirms that, by the 
time the ovum reaches the lower end of the Fallopian tube, its capacity 
for impregnation is lost, and experiments which have been made, by tying 
the Fallopian tubes in the lower animals before copulation, so far corro- 
borate this view, which is now generally entertained. There can at least 
be little doubt that in the great majority of cases among Mammalia, and 
most probably in the human subject, it is in the upper half, or third, of 
the Fallopian tube that the meeting of the ovum with the semen takes 
place. 

How, then, do the spermatozoa reach the ovum ? It cannot for a 
moment be doubted that the spermatozoa make their way upwards, in 
man, as in the lower animals, from the vagina, to that point where they 
meet the ovum.^ There are various possible agencies by means of which 
this movement may be effected : 1st. By the action of the spermatozoa 
themselves, which may undoubtedly determine a motion, although it is 
difficult to conceive why such motion should be in a definite direction. 
It is highly improbable, therefore, that this is the sole cause. 2d. By 
the action of the vibratile cilia. This might account, no doubt, for the 
movement from the middle of the cervix upwards ; but in cases where 
impregnation has resulted from contact without penetration, the absence 
of cilia between the vulva and the cervix must leave the movement along 
this part of the tract to the operation of some other agency. 3d. Mus- 
cular peristaltic contractions may also act by propelling the semen in a 
definite direction. There are various parts of the course which the 
semen must traverse to which one or other of these forces may be more 

' Some speak of the "ovum" only after impregnation, and term it "ovule" prior 
to this. 

7 



98 DEVELOPMENT OF THE OVUM. 

applicable, but it is more than likely that muscular peristaltic action is 
the chief moving power. 

The absence of the vibratile cilia during a menstrual period from the 
shedding of the epithelium may raise a difficulty as to the acceptance of 
one of the above theories, most likely to suggest itself to those who en- 
tertain the strongest views as to the identity of the rut and menstruation. 
But, in regard to this, it must be observed, that the period at which 
impregnation is most likely to occur, is some days after, or shortly before, 
menstruation; in the one case, the changes in the epithelium of the ute- 
rine mucous membrane not having yet commenced, and, in the other, a 
sufficient period having elapsed to admit of its reparation. 

A sketch of the development of the ovum, from the period of impreg- 
nation onwards, will be reserved for the following chapter. 



CHAPTEE VI. 

DEVELOPMENT OF THE OVUM. 

Disappearance of Germinal Vesicle. — Cleavage of the Yolk. — Development of the 
Blastodermic Vesicle. — ^'■Serous" and '■'Mucous'" Layers. — The Area Germi- 
nativa and Primitive 7 race. — Formation of the Embryo; of the Umbilical 
Vesicle and Omphalo-mesenteric Vessels ; of the Amnion ; of the Allantois and 
Umbilical Vessels; of the Chorion. — The Liquor Amnii. — TheVitriform Body. 
— The Decidua : ivhatisitf — Decidua-Vera ; Rejiexa; Serotina. — Early con- 
nection of Ovum with Decidua. — The Umbilical Cord: Vessels; Gelatine of 
Wharton.., etc. — Knots on Cord. — The Placenta — in Birds : in Non-Placental 
Mammals : in Ruminants : in Man : Maternal and Foetal Surfaces of: Ma- 
ternal Circulation in : Curling Arteries : Sinuses : Veins. — L'cetal Portion : 
Arteries: Tufts or Villi: Veins. — Functions of the Placenta.— Structure of 
Villi. 

The development of the ovum in the Mammalia, and especially in 
Man, is, as regards its earlier stages, a subject still involved in no little 
obscurity. The important results which have sprung from the studies in 
comparative physiology, associated with the names of V. Baer, Rathke, 
Bischoff, Remak, KoUiker, and many others of scarce inferior merit, 
enable us, with a certain amount of confidence, to fill up gaps in an 
account of human development, which the very rare opportunities afforded 
of examining human ova would probably never have revealed, but which 
the application of strict analogical reasoning enables us to supply. On 
these principles, the following sketch is based. No attempt will, how- 
ever, be made to follow the development of individual organs ; but merely 
to indicate, in what appears to the writer to be the simplest possible 
manner, the mode in which the envelopes of the embryo are evolved, and 



DEVELOPMENT OF THE OVUM. 



99 



the provision which, in successive stages of growth, is made for its nutri- 
tion. 

The disappearance of the germinal vesicle is one of the earliest, changes 
which has been observed. This is not nece^ssarilj associated with im- 
pregnation, but is rather a sign of the complete maturation of the ovum. 
Modern physiologists indeed appear to believe that, as a rule, it has 
nearly-, if not entirely, disappeared at the time of the rupture of the 
Graafian vesicle, and that it is actually extruded from the substance of 
the yolk, its fluid contents being, by rupture of the delicate capsule, 
effused in the space intervening between the zona pellucida and the sur- 
face of the yolk. On escaping from the ovary, the ovum is still covered 
with some of the cells in which, within the Graafian vesicle, it was im- 
bedded. The yolk becomes more compact, and, as it were, condensed. 
In the inner half of the Fallopian tube, the cells of the proligerous disk 
have disappeared, and their place is occupied, on the external surface of 
the ovum, by a thin albuminous layer, which is analogous to the white 
of the egg in birds. This albuminous layer becomes, in the first instance, 
thicker, but subsequently becomes gradually thinner, and ultimately dis- 
appears, or is incorporated with the subjacent zona pellucida. There 
now commences that most remarkable series of changes preparatory to 
the formation of the embryo, known as the segmentation^ or cleavage of 
the yolk. 

The first step in this process consists, as is shown in Fig. 49, of the 
fission of the mass of the non-nucleated protoplasmic yolk into two equal 



Fig. 49. 



Fiff. 50. 



Fi^. 51. 




Successive Stages of the Cleavafre of tlie Yolk. 



portions, by a deep furrow on either side, which ultimately, by uniting 
in the centre, completes the division. These again, by a repetition of 
the process, become subdivided, so that four spheres are now observed 
to occupy the cavity of the zona pellucida. After precisely the same 
fashion, the spherules become still further subdivided into 8, 16, 32, 64, 
and so on, until, on the arrival of the ovum at the uterine extremity of 
the Fallopian tube, the yolk presents the appearance shown in Fig. 51, 
which has been compared to a mulberry. It is to be observed further 
that a clear 2:lobule or nucleus is observed in each of the two orio;inal 
yolk spheres, and that these are reproduced, para passu, in the progress 
of the segmentation as shown in the figures. To these nuclear bodies 
the name of hlastide has been given. It is from the germ mass thus 
formed that the whole organization of the embryo is gradually evolved. 
In Mammalia, the process of segmentation affects the whole of the yolk. 
But there are great differences in this respect in other animals. In Birds, 



100 



DEVELOPMENT OF THE OVUM. 



and Reptiles, the cicatricula, or white spot, lying on the side of the yolk 
which floats uppermost, alone undergoes this process. A distinction is, 
therefore, to be made between the ova of these animals in which the yolk 
is entirely segmented, and is therefore germinal, and those in which a 
part only is directly germinal and another is nutritive. 

The yolk cleavage sets in within a few hours after the ovum has entered 
the tube, and the process probably occupies, in the human subject, not 
less than eight days. This is about the time at which the ovum is sup- 
posed to arrive in the uterine cavity, being then, we may suppose, about 
jIq of an inch in diameter. It now presents an appearance as if the 
whole of the granular orerm-mass had been absorbed. And to some ex- 
tent, no doubt, a process of solution or absorption has taken place, the 
centre of the cavity being again occupied by a fluid which is limpid and 
transparent. A more careful examination shows, however, that a large 
proportion of the granules become condensed towards the inner surface 
of the zona pellucida, assuming the form of true cells, of a hexagonal or 
pentagonal appearance from the pressure which they exercise upon each 
other. While these changes are going on, a rotatory movement of the 
yolk takes place, during which, possibly by centrifugal attraction, the 
cells retreat from the centre towards the circumference, and ultimately 
form a new membrane. The spheroidal vesicle thus formed within the 
zona pellucida, is the structure out of which, step by step, the entire 
embryonic structures are evolved. This is the blastoderm of Paneer, or 
hlastodermie vesicle of Bischoff" and Coste. 

From the shape of the cells of which it is originally composed, the 

ovum now presents the appearauce 
Fig. 52. show^n in Fig. 52, which indicates 

also a considerable increase in size, 
owing to the rapid augmentation of 
its fluid contents by absorption from 
the uterus, and the simultaneous de- 
velopment of the blastodermic vesicle, 
which now exhibits great and inde- 
pendent vital energy. At one point 
of its surface, a certain number of the 
original segmentary masses and cells 
form, by their aggregation, the ap- 
pearance which is represented in the 
same figure. This, which is at first 
round, and subsequently becomes 
oval, is recognized by its whitish 
opaque appearance. It is called the 
area germinativa, and constantly increases in size by the development of 
fresh cells ; and by and by splits into two layers, a division which rapidly 
extends throughout the whole blastodermic vesicle. The external of these 
two layers was originally called the "serous," the internal the "mucous" 
layer. As our object is to enter upon this subject, only in so far as is 
essential to a knowledge of the points in development which are of special 
obstetric interest, we shall here refer to these two layers only. There is 
another layer, however, intermediate between the two, which further 




External Surface of the Ovum, showing the 
Area Germinativa. 



EARLY STAGES OF DEVELOPMENT. 101 

subdivides as evolution advances, a knowledge of which is essential to a 
thorough description of the various organs. This was first called the 
^' vascular" layer, but there are many points in reference to it which are 
still under consideration, and in a measure involved in obscurity.^ 

The Area Gerrainativa, at first homogeneous in appearance, soon shows 
in its centre a clear space, called the area pellucida, hounded by a denser 
layer of cells, which are manifestly more opaque. The first appearance 
of definite embryonic structure is a shallow groove lying lengthwise in 
the area pellucida. This is the primitive trace, the earliest indication of 
the cerebro-spinal canal. If 

viewed in section, this groove ^^S- 53. 

(Fig. 53 a) is seen to lie 
between two lateral eminen- 
ces called the lamince. dor- 
(c c) which we here 




demonstrate, as it illustrates r^^'^' ^ .^,^ ,. , , ,. . ,^ j, , 

. ' Diagram stLowm? the earliest formation of the Embryo. 

a law m development, oi 

which, in the evolution of special organs, we find many illustrations. 
This diagram, after Remak, is the only one in the series in which the 
middle layer (^mesohlast) is indicated, showing at o the first trace of the 
vertebral column, and at p p the subdivision of this layer, indicating the 
origin of the pleuro-peritoneal cavity. The lowest in the figure is the 
mucous layer [hypoblast'). In the development of the tube of which the 
groove is the trace, the lamin;ie dorsales rise, and, folding together, meet 
in the middle line, and there unite.^ Consequently, the cutaneous or 
corneal layer (^Hornhlatt of Remak) originates on its surface elements 
which, within the tube, ultimately become the cerebro-spinal nervous 
centre. Among other instances of this method of development by invo- 
lution, the formation of the lens and vitreous body, in the construction 
of the eye, is a striking example, both the cuticle and these structures 
being originally portions of the same external or corneal surface. 

The albuminous layer having now disappeared, and the zona pellucida 
having in great part lost its thickness, the formation of the embryo be- 
comes more distinctly manifested by a rolling or folding inwards both of 
the sides and of the extremities of the area germinativa. Kt this stage, 

' These three la^^ers of the blastoderm are now called epiblast, mesoblast, and hypo- 
bJast. 

"From the epiblast -proceed the epidermis and its appendages, the great nervous 
centres and the principal parts of the eye, ear, and nose ; one laver of the amnion 
and yolk sac, and in mammals, probably the outer layer of the permanent chorion. 

"From the hi/ poblast proceed the epithelial lining of the whole alimentary canal 
(excepting that of the mouth), and of the lungs, the epithelial lining of the ducts 
of the glands connected with the alimentary canal, and also the deep layer of the 
yolk-sac and allantois. 

"From the mesoblast proceed in general all the parts of the skeleton, the muscles, 
fasciffi, and tendons, the peripheral nerves, the muscular and fibrous coats of the 
alimentary canal, and all other visceral passages, the serous membranes, the paren- 
chyma of many glands, and the genito-urinary system, together with the outer layers 
of the amnion, the vascular layers of the yolk-sac, the allantois and the amnion, and 
the foetal part of the placenta."' (Quain's Anutomi/, 8th edition, vol. ii.) 

2 The most recent observations show that this trace or groove is but a temporary 
arrangement. It appears originally in the narrow or caudal extremity of the area 
germinativa, but the true medullary groove begins higher up, and growing downwards 
towards the caudal extremity, replaces as it were the primitive trace. 



102 



DEVELOPMENT OF THE OVUM 




Diagram sho-vving early stage of 
Developnieut. 



Fig. 55. 



the embryo has the appearance of a curved gutter, with a larger (cephalic) 
and a smaller (caudal) extremity. A glance at the diagram (Fig. 54) 

will show that its external or epidermic surface 
is continuous with the external or serous layer 
(5) of the blastodermic vesicle. About this 
period, the blastodermic vesicle becomes divided 
into two parts, as is indicated by the horizontal 
dotted line in this and the following diagram, 
the lower portion being emhryonic^ and the 
large cavity above forming the umhilical vesicle 
(u). The embryonic portion constantly in- 
creases, while the umbilical vesicle progres- 
sively diminishes, as if the development of the 
former took place at the expense of the latter : 
this is made clear in the series of diagrams. 
The two small projections {a a) show the earliest stage of the formation, 
by a process of involution, of the amnion^ an important structure, the 
further development of which will be traced presently. The blastodermic 
vesicle, then, is surrounded by the zona pellucida (2). It is itself com- 
posed of two layers, the external or serous (s), which is continuous with 
the external surface of the embryo, and from which the amnion is de- 
veloped ; and the internal or mucous (w), which subsequently subdivides 

to form the mesoblast. If we look, however, 
at the mucous layer, in its original and simplest 
form, we may assume that the umbilical vesicle 
and the intestinal surface of the embryo are 
identical and continuous, both being derived 
from the same layer. 

In Fig. 55, the same parts are shown in a 
more advanced stage of development. The 
embryonic portion of the blastodermic vesicle 
is more defined, and of larger size, and the 
umbilical vesicle is diminished in a Correspond- 
ing deojiee, while the communication between 
The first indications are now shown 
on the latter of a vascular system. This is the omphalo-mesenterie 

system, or circulation of the yolk, from 
which is formed ultimately the portal cir- 
culation of the foetus. The umbilical vessels 
spring, as we shall see, from another source. 
The amnionic folds (a a) are now seen to 
project more over the embryo. 

The next step in the process of de- 
velopment is shown in Fig. 56, in which 
the whole ovum shows an increase in size. 
The amnionic folds project so far that they 
are nearly in contact, the embryo being 
thus inclosed in a sac which has as yet 
^ , , . , ^ an openino; at (a a). About this period, 

Development in a more auvaQced ^ . '~ ^ ■' i 77 • 

Stage. ^ very important structure, the allantois, 




Further Development of the Ovum. 



the two is rendered more distinct. 



Fiff. 56. 




THE AMNION AND CHORION 



103 



makes its first appearance under the form of a small pear-shaped vesicle 
(jc), which springs from the mucous and vascular layers, near the caudal 
extremity of the embryo. This little organ has, as we shall find, a most 
important part to play in providing an apparatus, and channel of com- 
munication, whereby the circulation and respiration of the foetus may 
be efficiently maintained. This vesicle, in birds, reaches a very con- 
siderable size, so much so as completely to surround the yolk sac, so 
that, through the shell and its membrane, it comes into actual relation 
with the external air. In those mammals in whom the placenta (an 
organ to be hereafter described) surrounds the ovum, the allantois 
has in like manner a considerable development ; but, in the human 
race, where its function, though not less important, may be said to be 
comparatively of a temporary nature, the allantois never reaches any 
considerable size. It is originally hollow, and is the receptacle for 
the secretion of the Wolffian bodies, and subsequently for that of the 
true kidneys when formed. It is not, however, correct to suppose 
that it gives origin to the urinary bladder, but its pedicle, the ui^a- 
cJius^ forms the suspensory ligament of the bladder, and may be traced 
in adult life. At a very early period of its formation, vessels make 
their appearance upon it, and shortly after this (probably in a few days) 
it becomes elongated and, as it were, projects these vessels, which are 
the umbilical arteries and veins, towards the surface of the ovum, with 
which it comes into contact at that part where the placenta is about 
to form. It is not, indeed, until this has taken place that the outer of 
the two foetal envelopes may properly be said to be completed. 

The foetal covering here alluded to is the cJiorion, which may thas be 
considered as composed of the external or serous layer, with the remains 
— should these still exist — of the 
zona pellucida on its external, and 
some portions of the allantois on 
its internal surface. The chorion, 
thus constituted, becomes abun- 
dantly supplied with vessels from 
the allantois, which soon pervade 
it in its whole extent, as is shown 
in the accompanying diagram (Fig. 
57). Prior to this, small projec- 
tions have appeared on the exter- 
nal surface of the chorion, which 
are the rudiments of the Ions; 
shaggy villi with which the ovum 
is seen to be covered in abortions 
occurring in the early weeks of 
pregnancy. The allantois having 
now fulfilled its function, dwindles 
to a mere cord, within which a 
minute vesicle may be detected by careful examination, as representing 
the original cavity. It is probable that the allantois forms about the 
tenth day after impregnation, and runs its course in a few days more ; 
so that it is not to be wondered at that some physiologists have doubted 



Fm. 57. 




Completion of the Amnion, and formation of the 
Umbilical Cord. 



104 DEVELOPMENT OF THE OVUM. 

its existence in the human race, seeing that its limits have not been 
clearly demonstrated. Analogy, however, enables us confidently to 
assume that, without it, there could be no vascularity of the chorion, a 
condition which would involve a speedy arrest of development. At first, 
it carries two arteries and two veins ; but the vein of the right side be- 
comes obliterated about the fifth or sixth week, so that there are found 
from this period till the time of birth, two umbilical arteries and one 
umbilical vein. 

After the formation of the allantois, the umbilical vesicle rapidly 
shrinks, and is often seen, in abortions at the sixth week, under the form 
of a vesicle no larger than a pea, connected with the small intestines of 
the embryo by means of a long and narrow pedicle ; and its flattened 
yellowish vestige may with care be detected much later, lying not far 
from the place of implantation of the umbilical cord into the placenta, 
between the chorion and amnion. (See Fig. 71.) The omphalo-mesen- 
teric vessels atrophy, along with the organ to which they belong ; and 
the communication which existed between the vesicle and the alimentary 
canal, becomes more and more curtailed, and ultimately obliterated. 
There can be no doubt, however, that in the earliest stages of the de- 
velopment of the ovum, and up to the period of the formation of the 
allantois, the embryo derives its chief nourishment from the whitish- 
yellow fluid, which is contained in the umbilical vesicle, and which has 
been found to contain numerous fatty cells and globules. But with the 
formation of the allantois and the vascularity of the chorion, the neces- 
sity for nutrition from this source ceases, and the umbilical vesicle, which 
at one time formed the greater part of the bulk of the ovum, now withers, 
and ultimately disappears. 

At the same time that this dwindling of the umbilical vessel takes 
place, the development of the amnion goes on with considerable rapidity. 
In Fig. 57 the completed process of involution, which results in the for- 
mation of the cavity of the amnion, is shown, as are the earlier stages in 
the preceding diagrams. The amnion thus forms a close cavity or sac, 
which consists of two layers, and is contractile; and in which, hence- 
forth, the foetus floats freely, protected by the fluid which it contains 
from shock and external influences. By the absorption of the original 
amnionic folds, at the point where they come into contact (see the dotted 
line below «), the amnion becomes completely detached from that portion 
of the serous layer of the blastodermic vesicle, which we have shown to 
enter into the formation of the chorion. The amnion thus forms a sheath 
for the umbilical cord, and from the margins of the ventral aperture or 
umbilicus, is continuous, as it has been from the first, with the surface of 
the embryo. When completed, it constitutes the internal membrane of 
the ovum ; and from its inner surface there exudes a liquid (liquor 
amnii^ which is essential to the safety and further development of the 
embryo, — not by aflbrding it nourishment, to any extent, but by the 
mechanical support and protection which it constantly maintains. The 
liquid consists of water, holding in solution a small quantity of albumen 
and salts. It is at first limpid, but, towards the end of pregnancy, it 
becomes of a higher specific gravity, and is often milky, or of a darker 
color, with numerous albuminous flakes. When the hue is greenish, or 



ESSENTIAL STRUCTURES OF THE OVUM. 105 

dark in shade, this is probably due to the escape of \he contents of the 
bowel. The quantity of the liquid varies extremely, and that, too, with- 
out apparent cause ; and while its actual quantity may be said to aug- 
ment during the whole period of gestation, it is generally admitted that, 
relatively to the size of the foetus, it increases during the first half of 
pregnancy, and diminishes from that time onwards. In addition to the 
protection of the foetus from shock, which must manifestly be exercised 
to the greatest advantage during the early months, the liquor amnii gives 
room for the movements of the foetus, which we cannot doubt to be essen- 
tial to its proper development, and for changes in position or posture, in 
obedience to the laws of gravity. It protects, also, the umbilical cord 
from pressure : and, during labor, prevents the walls of the contracting 
uterus from pressing prematurely on the surface of the child, while it 
safely and expeditiously effects the mechanical dilatation of the os. 
Finally, omitting, for the present, the possibility of its being a source of 
nutriment, it is of great assistance to the accoucheur, — preventing the 
firm contraction of the uterus upon the child, and so facilitating, in many 
ways, both manual and instrumental operations. 

External to the amnion, the interval between it and the chorion is 
occupied by a soft gelatinous substance, to which Yelpeau gave the 
name of vitriform body ; and embedded in which are the remains of the 
umbilical vesicle. The lono; pedicle of the umbilical vesicle penetrates 
the cord, by an aperture in its sheath. The closure of the amnionic 
cavity, the formation of the allantois, and the connection thus ultimately 
established between the embryo and the exterior of the ovum, complete 
the essential parts of the ovum. The latter now consists — ■ 

a. Of the Embryo : 

h. Of the Liquor Amnii, in which it is suspended: 

c. Of the membrane of the Amnion, which is the internal membrane of 
the ovum, is continuous with the external surface of the embryo, and 
forms a sheath to the umbilical cord : the pedicle of the umbilical vesicle 
passes through an aperture in this sheath: 

d. Of the Urachus or pedicle of the Allantois, and other parts which, 
together, form the Umbilical Cord: 

e. Of the Chorion, — the external envelope of the ovum. 

These parts, although deriving, no doubt, the supply of material neces- 
sary for their growth from the parent, are strictly of embryonic origin, 
or spring from parts which take their rise in connection with the embryo 
or the peripheral membranes of the ovum. Other structures, however, 
are simultaneously developed, which may be regarded as in whole or in 
part maternal. 

The outermost of the three coverings of the ovum, one which, accord- 
ing to every hypothesis hitherto advanced, must be looked upon as purely 
maternal in its origin, is the decidua. The theory originally propounded 
by Hunter, and adopted by the great bulk of physiologists of the early 
part of the present century was simply this : The congestion and excite- 
ment coincident with impregnation, caused, on the inner surface of the 
uterus an exudation of a new formation of the nature of coagulable 
lymph, which closed the orifices of the Fallopian tubes, leaving only one 



106 



DEVELOPMENT OF THE OVUM. 



Fig. 58. 




Diaaram, showing Hunter's 
theory as to the formation of 
Decidua. 



opening, corresponding to the internal os. The ovum, on its arrival in 
the uterine cavity, Avas assumed to push this membrane before it, so that 
the decidua became naturally divided into two parts, that which adhered 
to the uterine surface (^decidua vera, a,), and that which invested the 
ovum (^decidua reflexa, h.') Subsequent observation having shown that 
a portion of membrane, identical in its structure 
with these, was found behind the ovum, — be- 
tween it and the uterine wall, — this was re- 
garded as a formation subsequent to the arrival 
of the ovum, and was named the decidua sero- 
tina. This theory owed its general acceptance 
to the fact that it afforded an explanation of 
what had frequently been observed in abortions 
• — that the complete ovum was found to be en- 
closed in a pouch, which was shed from the 
uterus, and which thus derived its name. The 
view universally adopted by modern physiolo- 
gists is, however, quite different from this. 

We have already seen in our notice of the 
mucous membrane of the uterus, as observed in 
w^omen who have died during menstruation, that 
it is at these periods greatly hypertrophied and congested, and, iii conse- 
quence, throAvn into convolutions. (See Fig. 47.) Up to a certain point, 
the changes after impregnation are identical with those which accompany 
the menstrual molimen. According to Robin, the columnar and ciliated 
epithelium is partly exchanged, during the progress of pregnancy, for 
the tessellated variety, and partly desquamated. Sharpey and Weber 
found that the decidua vera was, allowino; for the chansi-es above men- 
tioned, identical in structure with the mucous membrane of the uterus ; 
and, especially, that the characteristic tubular glands were abundant, 
and much more distinct than in the unimpregnated condition. By, others, 
the orifices of the Fallopian tubes were found to be free. As regards 
the decidua reflexa, greater difficulties had to be surmounted. If this 
portion of the membrane be examined at an advanced period of preg- 
nancy, it is found to be thin and transparent, if indeed it can be sepa- 
rated from the decidua vera ; and it then presents no trace wdiatever of 
the tubular glands. At an earlier period, the glands are found to be 
absent in the central or more prominent portion only, becoming more 
distinct, however, as we approach its point of contact with the decidua 
vera. In fact, we may assume, with Coste, that the views of Bischoff 
are, on this subject, incorrect, and that, on its first formation, the decidua 
reflexa is identical in its structure with the decidua vera. All this points 
irresistibly to the conclusion that the decidua is nothing else than the 
uterine mucous membrane, altered to suit the requirements of the case. 

The main difficulty which, on this view, will suggest itself to the student 
of physiology, is to account for the manner in which the ovum gets be- 
hind the mucous membrane. Here we must be content with theory; but 
it is a theory founded directly on the facts which modern physiology has 
revealed, and certainly preferable to that of Hunter, more especially as 



FOEMATIOX OF THE DECIDUA. 107 

accounting for the existence of the decidua serotina. The ovum, on its 

arrival in the uterine cavity, is for a certain time free from all adhesion. 

Probably, it becomes arrested 

in one of the sulci between Fig. 59. 

the convolutions into which ,,^--" ~~^^-^ 

the mucous membrane is .-^^ -^ - - ^^^\ 

thrown, and there it contracts ^, : ' >v 

adhesions, at the point where ^^ ^^-' --^- o^^^ ^ 

the placenta will presently be -^ '" ^^.^^ "--' 

formed. On either side of ' '^ 

it, there now rise projections Formation.: l . lu; first stage. 

of the mucous membrane 

(Fig. 59), as we have seen to Fig. eo. 

occur in the formation of the <. 

amnion, and in that of the 
organs of special sense : the ^^ 

folds meet in the centre, and 
the evolution is complete, a, 
(Fig. 60) being the decidua ^ 
reflexa, h, the decidua vera^ 
and c, the decidua serotina. 
The villi, which at this time 
are abundantly developed on 
the surface of the ovum, are 
assumed by some to be re- 
ceived into the orifices of the uterine glands, and, indeed, Sharpey ac- 
tually found this to take place in the case of the bitch. The simple fact 
of extra uterine pregnancy seems, however, sufficient to show that, although 
this may occur, it is by no means essential as a step in development. 
But, whatever view we may be inclined to take of the theory, the facts 
are these: if we open the uterus of a woman, about the fifth week of 
pregnancy, we find, almost certainly, a tumor in the neighborhood of the 
fundus, and projecting into the cavity of the uterus. The Fallopian tubes 
are open, and the membrane which covers the tumor is continuous, and 
identical in structure, with that which lines the uterine cavity, the glands 
being probably more distinct near its base. The tumor, on being incised, 
discloses a cavity containing an ovum. All this seems to indicate that 
the modern theory is, at least, more likely to be correct than any hitherto 
advanced. 

If, in the course of such an examination as has just been indicated, 
the cavity be carefully opened, and a flap turned doAvn, the ovum, quite 
uninjured, may then be observed, sometimes bathed in blood when blood- 
vessels have been injured. Its external surface will be seen, bristling 
with villi, and on the inner surface of the everted flap, small depressions 
or lacunae may be noticed, into which the villi dip, and by means of which, 
no doubt, material is obtained for the time from the circulation of the 
mother. If, again, we cautiously remove the ovum and wash out the 
cavity, we shall find that the lacunae on the side of the decidua serotina 
are much deeper, and more numerous. This marks the place at which 
the placenta is about to form. 



Formation of Decidua completed. 




108 DEVELOPMENT OF THE OVUM. 

If we look again at Fig. 61, we may observe that in the most project- 
ing part of the ovum, which is the centre of the everted flap, the mem- 
brane has become thin and exsanguine ; 
^^^' ^^' and here, even at this early period, we 

would probably look in vain for the tu- 
bular glands. This is the commencement 
of another and an important change which 
goes on, pari passu, with the develop- 
ment of the placenta. Those villi of the 
chorion which pass towards the decidua 
serotina are more and more developed, 
and become imbedded in the latter, the 
two together forming the placenta, an 
organ to be immediately described. So 
soon as this new connection is thoroughly 
established, the villi over the remaining 

Flap of Decidua Reflexa turned down, /» n .t t • • i 

disciosiug the o^um. surfacc of the ovum dimmish, or cease 

to grow in the same proportion; and, as 
the ovum extends, they become thin and scattered over that side of the 
chorion which is most distant from the placenta, and are ultimately ab- 
sorbed, the external surface of the chorion being then perfectly smooth. 
With this, the decidua reflexa loses its vascularity, the vessels becoming 
obliterated from the centre of the projecting part towards the circum- 
ference. As development progresses, the ovum steadily increases in size, 
and the cavity which exists between the two layers of decidua becomes, 
in consequence of this, encroached upon, until, about the third month, 
the two come into contact, and the whole of the uterine cavity is then 
occupied by the foetus and its membranes. It is impossible after this 
stage to distinguish or separate the decidua vera from the decidua reflexa, 
which has led Dr. A. Farre to think it probable that the decidua reflexa, 
after becoming extremely attenuated, ultimately disappears entirely. We 
do not doubt, however, that although it may become very thin, it may 
with care be traced. 

Let us now turn again to the interior of the ovum, the essential parts 
of which were completed by the formation of the allantois. The elonga- 
tion of the pedicle of the allantois and the obliteration of its cavity take 
place with great rapidity, and, at the same time, the cord becomes greatly 
increased in length. From this period onwards, the Umbilical Cord con- 
sists of the following parts : the amnionic sheath, which entirely surrounds 
it, save at one point, where a small slit gives egress to the pedicle of the 
shrunken umbilical vesicle ; the two umbilical arteries and the umbilical 
vein, which form the greater portion of the bulk of the cord ; that portion 
of the pedicle of the umbilical vesicle which extends from the umbilicus 
to the point of exit ; and, lastly, the remains of the pedicle of the allan- 
tois. By means of the villi of the chorion, acting, as Professor Owen 
has observed, like the spongioles of a plant, nutriment is extracted from 
the maternal soil in which it is imbedded, each vascular tuft being, as it 
were, an independent centre of respiration and nutrition. But, with the 
complete establishment of the umbilical communication — for it cannot as 
yet be termed a '' cord" — these functions become localized in the human 



THE UMBILICAL CORD. 109 

race, and there now begins to form, at the point, probably, where the 
allantois first touched the wall of the ovum, an important special organ 
of connection, the Placenta^ in which externally the umbilical cord ter- 
minates. The Umbilical Cord, being composed of the elements above 
detailed, conducts the foetal blood from the bifurcation of the abdominal 
aorta to the placenta by its two arteries, and brings back the same blood 
by means of its single vein, it having meanwhile undergone certain 
changes. The obliteration of the umbilical vesicle soon admits of the 
closure of the aperture alluded to, and thus reduces the contents of the 
cord to the vessels above mentioned, and the loop of bowel which still 
protrudes by the umbilical orifice. This communication between child 
and placenta varies considerably in length. At first it is short, and is 
also thick in proportion to the size of the ventral aperture, but soon 
becomes considerably elongated. Even at the termination of pregnancy, 
however, great varieties are observed, it being in some instances no more 
than a few inches in length, and in others extending; to five feet or even 
more. Its average length, at the full time, may be assumed to be some- 
where about twenty inches. The vessels, which are devoid of valves, 
and which give oft" no branches in the cord, are disposed in regard to 
each other, in a manner somewhat peculiar. Firmly bound together by 
a tenacious substance called the gelatine of Wharton, the quantity of 
which determines in a great measure the thickness of the cord, the ves- 
sels are invariably twisted like the handle of a basket. This does not 
take place in an irregular manner ; on the contrary, the twist is, nine 
times out of ten, from right to left, and, invariably, the vein forms, as 
it were, a centre or axis, around which the arteries are arranged in an 
irregularly spiral form. This twisting, which has been observed as early 
as the second month, is supposed to depend partly upon the movements 
of the foetus and partly upon a more rapid growth of the arteries than of 
the other tissues of the cord. On an average, the cord is about the 
thickness of the little finger. Many anomalies have been observed in 
its formation. One artery, three arteries, and even three veins have 
been met with, without anything untoward having occurred in the course 
of pregnancy. 

When the cord is too long, knots have frequently been observed upon 
it. These are, doubtless, due to the movements of the foetus, and are 
much more likely to occur if, along with great length of the cord, there 
is an excess of the liquor amnii. It is easy to understand how, under 
such circumstances, the foetus might float through a large loop, and a 
knot be the immediate or ultimate result. It is conceivable that danger 
might arise from this, in the course of labor, should any mechanical 
complication tend to draw the knot tighter ; but all experience seems to 
show that these knots are not to be looked upon as dangers, unless under 
such very exceptional circumstances. 

The cord is, as a general rule, of very considerable strength, as is 
shown in cases where — often in error — considerable force is brought to 
bear upon it, in attempts to remove the placenta when this organ is re- 
tained. At other times, a very moderate tension will suifice to break it. 
It is firmly adherent, at its foetal extremity, to the abdominal w^alls of 
the child, and, at the placenta, it is found to be intimately connected 



110 DEVELOPMENT OF THE OVUM. 

with the tissues of the chorion. Externally, its connection with the 
amnionic sheath is of a slighter character, and this is more particularly 
to be observed near the placenta, where the amnion often passes off from 
it near to the point of its insertion, and thus forms a sort of infundibuli- 
form investment, which has been noticed by many authors. Nerves and 
lymphatics have been described as appertaining to the umbilical cord ; 
but these, if present, are so difficult to trace that their existence is very 
generally doubted. 

The Placenta. — The ovum is, as we have seen, supplied with nutri- 
ment, in the first instance, directly from the contents of the umbilical 
vesicle, through the channel of communication which exists between it 
and the intestinal canal, subsequently, in all probability, through the 
medium of the omphalo-mesenteric circulation ; and, at a still later period, 
before the formation of the allantois, through the villi of the chorion, by 
imbibition. When, through the agency of the allantois, the umbilical 
vessels have been projected to the Avails of the ovum, a more direct means 
of communication is at once established. In the lowest Mammalia, 
which are hence called " non- placental," no further change takes place 
in this respect — the whole periphery of the chorion exchanging elements 
with the maternal parts, as in the early human ovum — until the period of 
birth. In many of the higher Mammalia, as in the Ruminants, certain 
portions of the surface of the ovum contract with the super-imposed 
maternal parts more intimate adhesions, while other parts become more 
comparatively deprived of their villi. An increase of tissue at these 
points gives rise to the formation of " cotyledons," which may be looked 
upon as so many miniature placentae, the structure forming the cotyledons 
being in these animals permanent. Many other and interesting varieties 
are observed, among which we may mention the diffused placenta of the 
mare and pig, and the zonal placenta of the Carnivora. In man, how- 
ever, and the higher orders, the mass is confluent and concentrated at 
one spot, and thus forms the single connective organ which is known as 
the Placenta. 

The disappearance of the villi over the remaining portion of the sur- 
face of the chorion, concentrates within the new organ the functions of 
nutrition and respiration, which it has thenceforth to discharge. A study 
of its structure is of peculiar interest to the obstetrician, as any diseased 
or other condition which may affect the due performance of its functions, 
must necessarily exercise an important influence on the healthy and 
normal development of the embryo. In many of the animals in whom a 
placenta exists, that portion which is derived from the ovum may be 
readily separated from the part which is of maternal origin ; but, in the 
human placenta, no such separation is in any way possible, so intimately 
are the two elements incorporated together. We must, nevertheless, 
look upon the placenta as composed originally of two distinct parts or 
layers, which are accordingly named the maternal 2iU.d. foetal portions of 
the placenta. 

The maternal portion is developed out of that part of the uterine 
mucous membrane to which the ovum attached itself on its arrival in the 
uterus. In other words, it is the decidua serotina. No sooner has its 
formation commenced, than the bloodvessels in the corresponding region 



STRUCTURE OF THE PLACENTA. Ill 

of the uterus become notably enlarged, the arteries retaining their 
characteristic spiral form, while the diameter of the venous trunks be- 
comes so much increased, that they are now called sinuses. In the 
earlier stages of formation, the maternal and foetal vessels are easily 
seen to run in distinct structures, which may be separated artificially 
from one to another, without rupture of any of the vessels. But, as the 
placenta becomes more consolidated, the interweaving of the two sets of 
structures becomes more intimate, by the thinning out of the intervening 
material, while the villous ramification of the foetal part, becoming more 
and more extended, is accompanied by a corresponding inflection of the 
maternal structure and vessels over every part of the villous surface ; so 
that, at last, there is produced so complete a combination or interlacing 
of the two as to make it quite impossible to separate them, or even to 
distinguish accurately the confines between the structure which w^as 
originally foetal and villous, and that which was maternal or decidual, 
and venous. Numerous observations have proved this, but none more 
distinctly than the experiments of Bonami, to which we shall immediately 
refer. Before doing so, however, it is necessary to observe that, on 
separating a placenta from its uterine attachment by cautiously drawing 
the parts asunder, it becomes obvious that a special tissue intervenes. 
This has been described as separating into two thin gelatinous layers, 
consisting when in situ of interlacing lamelliie, adhering at certain points 
only of their surface, and thus forming cells which may be shown on 
gently drawing the parts asunder. This is the inter-placental or inter- 
utero-pJacental tissue. 

Bonami demonstrated so far the structure of the placenta by colored 
injections as follows : He injected — 

1st Bed, from the iliac and ovarian veins : 

2d Blue, from the uterine arteries : 

3d White, from the umbilical vein : 

4th Yelloiv, from one umbilical artery, the other being tied to prevent 
the regurgitation from the anastomosis, which would otherwise have oc- 
curred. 

Careful observation and dissection then disclosed the following facts : 
that numerous red vessels w^ere visible through the amnion on the foetal 
surface of the placenta ; that red and blue vessels, the former straight 
and the latter spiral, were seen to pass in great aumbers through the 
utero-placental tissue, and to penetrate the placenta : and, finally, that a 
wJiite and yelhno network was distinctly seen on the uterine surface of 
the placenta. As no escape of the injected fluids had taken place into 
the intermediate tissues, the facts speak for themselves. 

Before proceeding to consider the more minute structure of the pla- 
centa, some general description of the physical characters of the mature 
organ may here be given. On its removal from the body, it is found to 
be a soft spongy mass, about twenty ounces in weight, and seven and a 
half inches in its greatest wddth. These are, of course, average dimen- 
sions, as it varies greatly in size ; and, on the same principle, it is de- 
scribed as being three-fourths of an inch thick in the centre, and one- 
eighth to one-fourth of an inch at the margin. It is usually somewhat 
oval in form, and the umbilical cord is inserted in the centre of its foetal 



112 



DEVELOPMENT OF THE OVUM. 



surface. It may be situated at any portion of the uterine surface, even 
over the os, but its usual site is the neighborhood of the fundus. It 
presents for observation an internal or foetal, and an external or uterine, 
surface. 

The internal or foetal surface (Fig. 62) is smooth, and is covered by 
the amnion, through which the vessels are distinctly seen to divide and 

Fig. 62. 




Foetal Surface of the Placenta. 



subdivide before plunging into the tissue beneath. The external or 
uterine surface (Fig. 63) is very different from the former. It is 
slightly rough on the surface, giving a peculiar granular impression to. 
the finger, very familiar to every obstetrician. It is, moreover, divided 
into irregular lobes, which may be easily torn or separated from each 
other. Indeed, examined from this side, the substance of the placenta 
may be said to be brittle. This surface is covered, as has been shown, 
by a thin layer of utero-placental tissue, through which, with some care, 
and by floating the placenta in water, the oblique passage of the veins 
from the uterus may be detected. The margin is continuous throughout 
with the membranes ; the foetal portion with the chorion, and the mater- 
nal with the decidua. 

Peculiarities in the structure of the placenta, and in the manner of 
its connection with the umbilical cord, are not very uncommon. What 
is known as "battledore placenta" is one of the most common of these, 
the cord being then attached, not to the centre, but to the margin of 
the placenta, giving it something of the form from which it has derived 
its name. In other cases, although much more rarely, small lobes or 
cotyledons are found detached from the general mass, as in a case figured 



CIRCULATION IN THE PLACENTA, 



113 



by Dubois ; while in twin cases certain modifications are obserred w^hich 
are essential to the dual development, but which will fall more naturally 
to be considered under the section relating to plural pregnancy. 



Fiff. 63. 







\ 




Maternal Surface of the Placenta. 



The structure of the placenta being thus complicated, it is not to be 
w^ondered at that great difficulties have been encountered in determining 
what is the nature of the communication which there takes place between 
the foetal and maternal circulating systems. An opinion long obtained 
that there was a direct commingling of the two currents, and that blood 
passed from the uterine arteries directly to the foetus, and, after there 
yielding a portion of its vital constituents, returned again by the uterine 
veins. The earliest attempts at injection, being no doubt unskilfully 
executed, seem to have encouraged this belief. Modern physiologists 
have long since dispelled this illusion, and the experiments of Bonami 
above cited demonstrate, along with others, that there is a maternal and 
a foetal circulation, each being distinct from the other as regards contin- 
uity of current down to its uttermost conduits. The vessels of the two 
systems are, however, in intimate contact throughout, as is made obvious 
at once by anatomical demonstration, and by a knowledge of the physio- 
logical necessities of the case. What, then, is the nature of the contact 
which permits of an interchange of material between the two ? 

In attempting to answer this question, and to describe the minute 



114 



DEVELOPMENT OF THE OVUM, 



structure of the placenta, it must be admitted that there are still many 
points in regard to which differences of opinion exist, and some difficulties 
which have yet to be explained. To enter upon a full consideration of 
these would ill accord with the expressed object of this work, but a gene- 
ral view of the case, as adopted by the best authorities, may here be 
briefly epitomized. The vessels which are seen to pass through the utero- 
placental tissue are, with an important exception, to be noticed afterwards, 
of two kinds, arteries and veins. The former the "curling arteries" of 
the uterus, as they are generally called, are of moderate size ; they do 
not anastomose much, nor are their ramifications very numerous, and 
they retain, within the placenta, in a certain degree their spiral disposi- 
tion. The veins are somewhat larger, straight in their direction, and with 
numerous anastomoses. Some have supposed that the connection between 
these veins and arteries was of the nature of a simple capillary circula- 
tion ; but the researches of Reid, Weber, and Goodsir, have shown that 



64, 




ection of the Placeata. 



their connection is of a special character, and offers the strongest possible 
contrast to a capillary system. According to them, the blood is conducted 
by the curling arteries into large irregular cells, or sinuses, the walls of 
which are thin, and composed of the lining membrane of the maternal 
vascular system only. These sinuses communicate freely with each other, 
and from them the blood is returned to the uterus through the veins which 
are.seen to pass through the utero-placental tissue. In fact, a consider- 
able portion of the bulk of the placenta, when the organ is replete with 
blood, is said to be composed of a great venous cavity, which dips so 
deeply into the chorion as to attain its foetal surface, but which is more 
distinctly seen in the tissue of the decidua. A large coronary vein has 



VILLI OF THE PLACENTA. 



115 



been described by Jacquemier and Meckel, as existing near the margin 
of the placenta. It is, they say, rarely complete, but presents in its 
course frequent interruptions, where the continuity is maintained by sub- 
division and anastomosis ; but as their observations on the subject have 
not been confirmed by recent research, we may assume that the existence 
of such an arran.ement is doubtful, certainly not constant. It is proper 
to add that the presence of a great venous cavity within the placenta has 
quite recently been seriously called in question. 

On the foetal side, the vessels, on reaching the placenta, divide at once 
into laro;e branches which are distinctly seen throuo-h the amnion. If this 

O I/O 

membrane be detached, which may easily be effected, as shown in the 
upper part of Fig. 62, both arteries and veins are observed to divide on 
the surface of the chorion. They then subdivide again and again, always 
dichotomously, and plunge into the thickness of the lobes. Here the 
arteries communicate freely with each other, so that if we inject one 
umbilical artery, the injection will return by the other. If, however, we 
tie the other, a successful injection will return into the umbilical vein, 
while the color of the injection will be observed on the uterine surface of 
the placenta. If we trace the arteries to their ultimate ramifications, 
we find that they are divided into innumerable tufts, fringes, or villi ^ 
which form in fact the bulk of the foetal placenta. Each tuft is occupied 
by one or more capillary loops, and the current, after passing through 
these loops, returns by the afiiuent canals, forming by their union the 
umbilical vein. The vessels of this capillary system difter from other 
capillaries in their greater size, their caliber being such as to admit of 
several blood-corpuscles passing abreast of each other. Throughout the 
whole placenta, the villi are found to project in the form of fringes into 
the placental sinuses, or, in other words, into the large venous cavity which 
is formed in the placenta by the union of these sinuses. Each fringe is 
thus bathed in maternal blood, and the foetal blood passing through each 
loop parts with its carbonic acid and receives oxygen in exchange, pre- 
cisely as occurs in the branchiae of aquatic animals. . And, further, as 
was first shown by Reid, a certain number of the foetal villi pass through 
the placenta, and dip directly into the larger sinuses of the uterus itself. 
Reid believed further, and his view is very generally accepted, that 
each tuft, in projecting into the placental cavity, pushed before it the 
lining membrane of this cavity, so 

that each foetal villus had a special Fig. 65. 

maternal investment. It is to be 
observed, however, that among Eng- 
lish physiologists, Dr. A. Farre 
combats this view, and that both 
Coste and Robin are opposed to it. 
They believe that the walls of the 
uterine vessels are eroded and per- 
forated by the villi, so that the walls 
of the latter are in direct contact 
with the blood of the mother. It 
will be observed, however, that either view of the case is sufficient to 
confirm the views first enunciated by the Hunters, that there is no com- 




Foetal viUi of the Placenta. 



(After Weber.) 



116 



DEVELOPMENT OF THE OVUM 



mingling of the two systems. The 

the arrangement and structure of the foetal villi. 



Fig. 66. 



accompanying illustrations refer to 
In Fig. 66, the cellu- 
lar covering which invests the villus is 
shown, except at its distal portion, where 
it has been removed to show the looped 
vessels. 

It must be remembered that the oxy- 
genation of the foetal blood is not the only 
function of the placenta ; but that through 
this channel also, material is supplied for 
the building up of the foetal tissues, and 
effete matter is removed. The observa- 
tions of Goodsir on this point, which are 
of the greatest possible interest, are cor- 
roborative of the views of Reid. These 
will be noticed when we come to speak of 
the nutrition of the foetus. 

The formation of the placenta com- 
mences in the latter part of the second 
month, and within a few weeks it acquires 
its essential characteristics. Small blood- 
vessels, for the special nourishment of the 
organ, pass from the uterus ; but neither 
nerves nor lymphatics have been, as yet, 
satisfactorily traced. The Hunterian view 
which has here been given of the structure 
of the placenta is that almost universally 
entertained, and has received important 
corroboration from the recent researches of Professor Turner,^ but it is 
proper to add that some physiologists have denied the existence of a sinus 
system. The names of Velpau, Radford, Ramsbotham, and Madge may 
be mentioned as holding more or less confidently the latter view ; but of 
late the contribution in refutation of the Hunterian theory which has 
attracted most attention is the Essay which Dr. Braxton Hicks presented 
to the Obstetrical Society in 1873. 




Ultimate foetal villus, highly magnified 
^After Ecker.) 



* Journal of Anatomy and Physiology, 1875. 



STRUCTURE OF THE EMBRYO. 117 



CHAPTEE yil. 

DEVELOPMENT OF THE EMBRYO AXD FCETUS. 

Demonstration of Embryonic Structures. — Characteristics and Development of tlie 
Foetus at the termination of each Month of Pregnancy, from the third onwards. 
— Dimensions of Mature Children. — Of the Presentation and Attitude of the 
Child in the Womb. — Causes of Cranial Presentation: theories of ^'•Physical 
Gravitation.,'' ^'■Volition.,'' and ^''Reflex Action.'' — The Fcetal Cranium: Su- 
tures: Fontanelles : Diameters. — Definition of the term '■'•Vertex.'^ — Functions 
of the Fcetus : Circulation: Respiration: Nutrition: Secretion. 

The term Foetus is, according to usage, not applicable to the product 
of conception, until the termination of the third month of gestation. Till 
then it is termed the Embryo. A study of the formation of the various 
embryonic structures is a subject which, in so far as human development 
is concerned, is beset with many difficulties. Viewed, however, in the 
light which comparative physiology has thrown upon it, our knowledge 
of the various organs of which the individual is composed, and of their 
growth from primal elements, may be considered as tolerably complete. 
The opportunities which arise of examining the bodies of women who die 
in the earliest stages of pregnancy are so few, that a very peculiar in- 
terest attaches to such reliable descriptions and representations as have 
hitherto been made. Among all these, none perhaps have received more 
unqualified commendation than the well-known drawings of Coste, from 
which the representations which follow have chiefly been taken. To at- 
tempt a demonstration, or even a narrative of the development of indi- 
vidual organs, is only suitable to a systematic treatise on Embryology. 
A very superficial description will serve our purpose here, and may suffice 
to show, more clearly than is possible by any means other than actual 
dissection, the relations wdiich the various parts of the ovum bear to each 
other, and to the maternal structures with which they are in contact. 

The accompanying representation of the product of an abortion about 
the twenty-fifth to the twenty-eighth day, shows the embryo and its mem- 
branes partly dissected, and magnified about seven times and a half. 
The Chorion, which has been opened in its whole extent, is recognized by 
its villi externally, and the numerous bloodvessels on its internal surface. 
Above, and to the left, is seen the umbilical vesicle, with the branches of 
the omphalo-mesenteric vessels coursing upon it. It lies, as has already 
been shown, between the chorion and the amnion, and its long narrow 
pedicle bearing the vessels is seen to pass into the umbilical cord, and, 
finally, to terminate at the summit of the single curve which marks the 
commencement of the intestinal convolutions. The right omphalo-mesen- 
teric artery is close below the intestinal canal, and included in the rudi- 
mentary mesentery. The left omphalo-mesenteric vein (v) is passing 



118 



DEVELOPMENT OF THE EMBRYO AND FCETUS. 



towards where the stomach is begmning to develop, to discharge itself 
into the common trunk of the umbilical veins. This is the commencing 
vena portse. The amnion (miii) has been freely opened to allow the 
embryo to escape, the caudal extremity being still within its cavity. The 
manner in which it is reflected to form the sheath of the umbilical cord 
is very clearly shown. The umbilical cord is opened in its whole extent 
to show its contents, including the canal of the urachus (pedicle of the 
allantois), which extends from the caudal extremity of the alimentary 
canal, closely accompanied by the umbilical vessels, and terminates at w 
in a cul-de-sac. On either side are the umbilical arteries and veins, the 
arteries springing from the lower part of the aorta, and the veins passing 
upwards, to unite before entering the liver and mix their contents with 
the general circulation, at the point of confluence (6>) beneath the heart. 

Fiff. 67. 




Ovum opened, and Embryo partly dissected. 



The vein of the left side, which may be observed passing through the 
centre of the mesentery, is the permanent one, and is already much 
larger than its fellow of the right side, which has been cut across at pp. 
The heart (7i), with its four cavities and the aortic bulb, is separated from 
the liver by an imperfect diaphragm. The Wolfiian body of the right 



STRUCTURE OF THE EMBRYO. 



119 




r\^. 



side (?f ) is shown passing from the heart to the inferior extremity of the 

intestine. Along its outer margin runs its excretory duct, which opens, 

along with its fellow of the other side, into the cloaca behind the rectum. 

The greater relative size of the cephalic extremity of the em.bryo is a 

striking peculiarity which at once attracts attention. 

The rudimentary eye («) is remarkable, chiefly in 

respect of its lateral position. In front of it is the 

right nasal fossa, and below it, at e, is the earliest 

trace of the internal ear. The large bucco-nasal 

cavity, with the three branchial arches beneath it, 

also attract special notice. 

Fig. 68 shows the same embryo magnified eleven 
times, carefully dissected, and seen from before. A 
portion of the intestinal convolution and of the 
mesentery has been removed, along "with the ante- 
rior thoracic and abdominal walls, and the umbili- 
cal cord, so as to bring into view the most of the 
Wolffian bodies on each side, and the heart. 

This representation shows more clearly the lateral 
position of the eyes («), and the distance between 
the nasal fossae (/), which are seen to communicate 
with the buccal cavity by a simple furrow. Between 
a and / are the rudiments of the superior maxillary 
bones. There is complete absence of all trace of 
palate. The position of the auricles, ventricles, 
and aorta, and the relation which these parts bear 
to each other at this age, are also more obvious 
from this point of view. Hidden to some extent 
by the heart, and separated from it by an incom- 
plete diaphragm, is the liver (/), which is of equal 
size on the right and left side, and presents a fissure 
on its lower surface : it covers and conceals the 
stomach. The vessel which is seen in section with- 
in this fissure (w), is the common trunk of the um- 
bilical veins. To the left, within the curve of the 
intestine (i), is the left omphalo-mesenteric vein (i'), 
the one which, being permanent, ultimately becomes 
the vena portae. Below the alimentary canal, and 
within the mesentery, is the right omphalo-mesen- 
teric artery (o). 

Extending downwards from the lower surface of the liver to the caudal 
extremity of the embryo are seen on either side the Wolffian bodies, with 
their excretory ducts close to their external borders. The white band 
running along their inner margin is the rudiment of the internal genera- 
tive organs. Between these parts is the divided mesentery, connected 
inferiorly with the alimentary canal (z). Immediately below this, the 
transverse slit shows a section of the cavity of the urachus, while the 
vessels which along with it form the umbilical cord are seen to surround 
it, the veins being below the arteries. It will be observed that one vein 
is already smaller than the other, and would ultimately have become 




The 



ame Embryo, further 
dissected. 



120 



DEVELOPMENT OF THE EMBRYO AND FCETTTS. 



Fiff. 69. 




obliterated. The buds or rudiments of the superior and inferior extremi- 
ties are quite distinct ; p is the common orifice of the genito-urinary 
system. 

Fig. 69 shows the branchial apparatus, rudimentary lungs, stomach, 
and liver, from behind. Above, is the inferior maxilla, the two lateral 
halves of which have already united in the middle 
line. Between this and the superior branchial arch 
is the rudiment of the tongue. From above down- 
wards are the first, second, and third branchial 
arches, separated from each other by slits or aper- 
tures {hraneliioe). Into the pharyngeal cavity which 
is thus exposed, the branchial apertures, the oesopha- 
gus, and the glottis open. The origin of the glottis 
is an oval eminence with a slit, which is indicated at 
h : c c are the rudimentary lungs pressed against the 
oesophagus, the right being lower than the left: (s) 
the stomach, at this period vertical in direction, and 
forming, with the oesophagus and alimentary canal, a 
nearly straight tube : {V) the liver, formed on either 
side of two nearly equal lobes, with a large furrow 
between them to accommodate the stomach. 

In Fig. 70 the heart is seen from behind. The 
lungs have been preserved in order to show the 
relation, in size and position, which they bear to 
the heart, (a a) common auricular cavity, the right 
side being evidently more developed than the left ; 
{v v) ventricular cavity, the left side larger than the 
right. 

The large vessel in the centre is the trunk common 
to the oraphalo-mesenteric, umbilical, and azygos 
veins. That to the rio;ht in the figure is common 
to the superior azygos vein (superior cava of the 
adult), and the inferior of the right side ; the smaller 
trunk to the left is common to the azygos, superior 
and inferior, of the left side. 
{oe) Section of oesophagus. 

The woman from whom the drawing (Fig. 71) 
was taken was, as may be inferred from the struc- 
ture of the OS and cervix, pluriparous. She com- 
mitted suicide about the fortieth day of pregnancy, and her body 
was subsequently examined at the Morgue in Paris. The anterior wall 
of the uterus has been divided vertically in its whole length, and the 
uterus thus laid open. " The cavity of the uterus," says Coste, " was 
partly occupied by a sort of soft fluctuating tumor, caused by the pre- 
sence of the ovum at this point. This tumor had externally all the ap- 
pearance and the organization of the mucous membrane which lined the 
uterus in the rest of its extent, and was situated on its posterior surface 
in the space between the two Fallopian tubes. The tumor produced here 
by the presence of the ovum did not yet occupy the whole cavity of the 
uterus. About the lower third of this cavity was free, so that the inte- 



Posterior View of Bran 
chial Apparatus, etc. 



Fig. 70. 




Posterior View of Foetal 
Heart. 



STKUCTURE OF THE EMBRYO. 



121 



rior of the uterus might be reached from the canal of the cervix without 
encountering any resistance. The internal orifices of the Fallopian tubes 
were, as well as that of the cervix, perfectly permeable, which was proved 
in the clearest manner by the observation of the orifice of the left tube, 



Fiff. 71. 




mk^ 





Dissection of an Ovum in situ, about the fortieth day. 

through which the ovum had passed on its way to the uterus." In order 
to demonstrate the structure and relation of the parts, a circular incision 
was first made through the decidua reflexa, and the flap thus formed was 
turned down towards the internal os. On its inner or everted surface 
(cZ), the lacunae are seen, which have already been described as existing 
at this period of pregnancy for the reception of the villi of the chorion. 
The ovum itself was then opened by a crucial incision, and the flaps of 
the chorion (c c) turned aside, so as to show the amnion (a). Through 
the walls of the latter membrane, the embryo is seen floating freely in 
the liquor amnii. The short and thick umbilical cord is observed passing 
from its ventral surface to that part of the surface of the chorion where 
the placenta would afterwards have been found. The situation of the 
umbilical vesicle in the cavity between the chorion and the amnion (a 



122 DEVELOPMENT OF THE EMBRYO AND F(ETUS. 

point which the student has occasionally some difficulty in understanding) 
is here very satisfactorily shown, and also the long pedicle which pene- 
trates the umbilical cord, and through which communication with the 
intestinal cavity of the embryo is still for a time kept up. The amnion 
is not yet of sufficient size to fill the cavity of the chorion, which still 
contains a portion of the vitriform substance {inagma rtticulQ of Vel- 
peau). This substance gradually disappears as the ovum increases in 
size, becomes compressed, and reduced to a layer of extreme thinness by 
the union of the amnion with the chorion, when all but a trace of the 
umbilical vesicle disappears. 

After the development of the placenta is completed, and the villi of 
the free surface of the chorion have been absorbed (as some suppose, by 
a procass of fatty degeneration), not only does the cavity between the 
chorion and the amnion disappear, but that which exists between the 
deciiua vera and the decidua reflexa is also gradually encroached upon 
by the growth of the embryo. When these membranes finally adhere, 
that cavity, too, is obliterated ; and now, for the first time, the product 
of conception may be said to occupy the whole cavity of the uterus. 
These changes are completed in the course of the third month. 

At this period, the foetus measures, in length, from five to six inches, 
and weighs about four ounces ; and the development of its limbs and 
ct'ier parts has advanced to such an extent, that the external parts may 
be said to be completely formed. The head, although still, relatively, of 
great size, is so in a much less degree than at an earlier period. The 
various cavities are completely closed. The formation of the palate, and 
the completion of the superior maxillary bones, has divided the bucco- 
nasal cavity. The branchial arches have disappeared as early as the 
fifth w^eek, with the exception of one fissure which has developed into 
the external ear. The umbilical cord is already longer than the embryo, 
has assumed its characteristic spiral form, and is attached considerably 
below the middle point of the vertical measurement of the child. Pre- 
vious to this, a loop of intestine occupied a portion of the cord, but this 
is now included, by contraction of the umbilicus, within the abdominal 
cavity. When that condition is permanent, umbilical hernia is the result. 
The globe of the eye is seen through the eyelids, and the pupillary mem- 
brane may be seen filling up the aperture of the iris. The nails have 
commenced to form, but are very thin, and almost membranous. The 
sexes are distinct. 

At the end of the fourth month^ the length of the foetus will be found 
to have increased to 7 inches on an average, and its weight to nearly 9 
ounces. On examining the head, the fontanelles are found to be of great 
size, and the sutures apart. Hair makes its appearance on the scalp, in 
the form of a slight down, which may also be noticed, in a still more 
delicate form, on the general surface. Fat begins to be deposited in the 
subcutaneous tissue. The muscular movements are brisk, although they 
may not yet have been recognized by the mother; and, in abortions which 

' The expression, "at the month," is very loosely employed hy many 

writers. When weeks are not mentioned, it is used in this work as meaning the 
completion of the ■ calendar month of pregnancy. 



GROWTH OF THE FCETUS. 123 

take place at this epoch, the movements are not only vigorous at the 
moment of birth, but may continue for several hours afterwards. 

With the completion of the fifth month, the length of the body will 
usually be found to have increased to from 8 to 10 inches, and its weight 
to from 10 to 12 ounces, or even more. 

At six months, it is from 11 to 12J inches, and w^eighs something more 
than a pound avoirdupois. The growth of the hair has considerably 
•advanced, and, in addition to that on the scalp, the eyebrows and eyelashes 
are also beginning to form. On the surface of the body the cutaneous 
structure now becomes more distinct, and the cutis vera and epidermis 
may usually, on careful dissection, be separated. The invariable wrink- 
ling of the surface is the result of the minute quantity of subcutaneous 
cellular tissue which is developed up to this time, in proportion to the 
other structures. In the male, the scrotum is very small and empty. 
The nails are already solid. 

In the course of the seventh month, the foetus is from 12 J- to 14 inches 
in length. The bulk becomes, from this period, steadily nicreased, by 
the deposition of subcutaneous cellular tissue, and the development of 
various organs ; but as the extent of this varies very greatly in different 
cases, it is difficult to say what should be stated as the average weight 
of this period. The bones of the cranium — in which the process of ossi- 
fication has already considerably advanced — become more prominent, and 
the intervals between them less. It is usually said, that about this time 
the pupillary membrane disappears ; but this is a question in reo;ard to 
which very considerable discrepancy of opinion has arisen. Velpcau 
denied the existence of the membrane in the human species at any period, 
but the opinion usually entertained in regard to this point, is that which 
we have mentioned — tliat it exists during pregnancy, up to the termina- 
tion of the seventh month, and then disappears. More modern observa- 
tions have, however, shown that it is incorrect to suppose that this mem- 
brane is lost at the time mentioned, but that it loses its vascularity in a 
great measure, and is so transparent that great difficulty is experienced 
in its demonstration. "In every instance," says Mr. Jacob,^ "where I 
have made the examination, I have found the meinbrana pupillaris ex- 
isting, in a greater or less degree of perfection, in the new born infant — 
frequently perfect, without the smallest breach, sometimes presenting 
ragged apertures in several places, and, in other instances, nothing exist- 
ing but a remnant hanging across the pupil like a cobweb. I have even 
succeeded in injecting a single vessel in the memhrana pupillaris of the 
ninth month." The eyelids now commence to open, and the testicles to 
descend in the scrotum. 

By the end of the eighth month, the increase in the bulk of the child 
and its general plumpness become very obvious, and this is shown still 
more clearly by taking its weight and measurement as before, when it 
will be found that whereas the longitudinal measurement has not increased 
beyond 17 inches, and is probably less, its weight will have reached 4 to 
5} pounds. The skin is now red in color, is no longer wrinkled, and is 
covered with down. Upon its surface is observed, in greater or less 

1 Cyclopaedia of Anatomy and Physiology. Art. " Eye." 



124 DEVELOPMENT OF THE EMBRYO AND F(ETUS. 

quantity, little masses of curdy or sebaceous matter, — a substance which 
is not of new formation, although it has become much more abundant. 
It may be noticed as early as the fifth month. The scrotum now contains 
one testicle, usually that of the left side. 

On the birth of the child at the termination of pregnancy, it will be 
found to measure from 19 to 24 inches, and to weigh about 100 to 130 
ounces (say, on an average, about Tj pounds avoirdupois). The um- 
bilicus was at one time believed to mark, at the full term, the middle point 
of the body, but the careful observations of Moreau and OUivier d'Angers 
shoAv that this is not the case, but that the middle point is generally about 
three-fourths of an inch above the umbilicus. With the complete devel- 
opment of the child, there is, of course, increased thickness of the nails, 
and a considerable addition to the adipose tissue, which sometimes, in- 
deed, is so considerable in quantity, as to raise the weight of the infant 
considerably above what has been set down as the average, and that with- 
out any corresponding increase in its length. 

Many fables have been narrated as to children which have been born 
weighing 20 to 30 pounds, and being 3J to 4 feet long. Twelve pounds 
is looked upon as a very great and unusual weight for a child at birth, 
but there are in this country few practitioners of experience who have 
not seen one or more such cases. In 4000 cases in the Maternite, Madame 
Lachapelle only found one child which weighed 13J pounds. Dr. Rigby 
says that Sir Richard Croft delivered a living child 15 pounds in weight. 
Mr. Owens delivered a woman of a still-born chikP which weighed 17 
pounds 12 ounces. Another case of a still-born child which was said to 
weigh 19J pounds is given by Cazeaux, but the weight was not taken by 
himself, and he seems to admit a doubt of it. Putting aside increased 
dimensions from disease, the above may be received as the extremes of 
authentic cases. It must be remembered, however, on the other hand, 
that many children, even at the full term, weigh much less than the ave- 
rage ; but it is a recognized fact that, if the child be mature, it rarely 
survives if it weighs less than 5 pounds at birth, although its chance is 
considerably greater, if a child of that weight be born prematurely. 
Female children weigh and measure less than males, and on this point it 
is said by Burns that 12 males are as heavy as 13 females. An inter- 
esting observation has been made by Dr. Guy, that " the mean w^eight of 
the bodies of still-born children exceeds the weight of such as have lived 
one day, by from about ^ to somewhat less than -^ ." In the last months, the 
size of the placenta becomes greatly reduced in proportion to the devel- 
opment of the child ; thus, at the sixth month, it is nearly half the weight 
of the child, while at the full term it is but a sixth or a seventh. 

There are few matters of higher importance, with reference to the re- 
lation which the foetus bears to enveloping and contiguous structures, 
than precision of nomenclature. At the same time, all who have had 
experience of the matter will confess that such precision, in regard to 
words which, in their vulgar acceptation, have a more extended significa- 
tion, is a matter of no little difficulty. To obviate, as far as possible, 
any confusion which may arise, we shall here attach to the three words 

» Lajicet, 1835. 



THE FCETUS IN UTERO. 



125 



Fi-. 72. 



" attitude," " presentation," and " position," a definite meaning to which 
we shall adhere in the sequel as closely as possible ; and it may further 
be remarked that a clear understanding on this subject has saved Ger- 
man authors from many of the errors and perplexities into which English 
writers have fallen. By the attitude or posture of the foetus in utero 
(Haltung) is meant the relation which its head, trunk, and limbs bear to 
each other ; by presentation (Lage) is implied the relation of the long 
axis of the child to that of the uterus ; while the word position^ in its 
strict and limited obstetrical sense (Stellung), indicates the relation which 
definite parts of the foetus bear to the anterior, posterior, or lateral re- 
gions of the abdominal or pelvic cavities. The varieties of a given pre- 
sentation, according to the relation which the lowest or presenting part 
of the child bears to the pelvic canal, con- 
stitute the most familiar use of the last 
named term. 

Presentation and Attitude of the Child 
in the Womb. — The shape of the womb 
being during the whole course of preg- 
nancy more or less oval, the foetus is found 
to assume from the earliest period a cor- 
responding presentation and attitude. In 
the early months of pregnancy, while the 
embryo still floats freely in the liquor amnii, 
and the envelopes of the ovum have not 
as yet come into contact with the uterine 
walls, the coincidence of the embryonic 
with the uterine ovoid is not an essential 
condition ; but, even thus early the ovoid 
form is being assumed, as is shown by the 
bending forwards, which approximates the 
cephalic to the caudal extremity. In this 
attitude, the development of the trunk and 
extremities proceeds, and, even at a period 
when there is still room for the foetus to 
stretch itself, and extend its limbs, we find it constantly with back and 
neck bent, and Hmbs drawn up and flexed. This attitude of the foetus 
becomes more marked as pregnancy advances ; and, ultimately, at the 
full term, it is very constantly to be observed, as is shown in the accom- 
panying diagram, with the vertebral column bent forwards, the chin in- 
clined upon the sternum, thighs strongly bent upwards on the belly, the 
knees bent, and the dorsum of the foot inclined towards the shin bone. 
The arms, more or less apart, are bent at the elbows, and the forearms 
are crossed or folded on the breast. In such a posture the child best 
adapts itself to the shape of the cavity in which it is inclosed, and which 
it pretty nearly fills. 

In no fewer than 96 per cent, of the cases of children born at the full 
term, the head of the child is turned — as in the figure — downwards 
towards the cervix of the uterus. The investigation of the causes which 
give rise to this law in gestation has long attracted the attention of ob- 
stetric writers. But, much as has been written on the subject, and in- 




Attitude of the Foetus in Utero. 



126 DEVELOPMENT OF THE EMBKYO AND FCETUS. 

genious as are many of the theories which have been advanced, it must 
be confessed that the problem has not yet been clearly solved. Few- 
have prominently noticed the fact above mentioned, that the ovoid form 
of the foetus is assumed while it is yet the embryo, and before it has 
been subjected to any influence arising from contact with the uterine 
walls. Manifestly, however, there is a cause — subsidiary it may be— 
which acts thus early on the embryo, to insure its safety at a later stage. 
But the point which, to the exclusion of others, has attracted, in this 
matter, the greatest amount of attention, is the presentation of the child, 
and the causes which lead to the inferior situation of the head in such an 
enormous preponderance of cases. 

The earlier theories which were propounded are more curious than 
instructive. It was very commonly assumed by the older writers that, 
in the early months, the head was normally uppermost, and that the 
sickness of early pregnancy was caused by an irritation of the dia- 
phragm, produced by the hair on the scalp. It was, further, believed 
that about the seventh month the presentation became inverted, and that 
now, for the first time, the head was normally beneath. 

Of all the theories which have been advanced to account for the pre- 
sentation of the head, none attracted so much attention, or gained so 
much credence, as that which led to the opinion that it was due simply 
to physical gravitation. The foetus, it was said, being suspended by its 
centre, in the liquor amnii, by means of the umbilical cord, its heavier, 
or cephalic, extremity must, of necessity, gravitate downwards; and this 
view was strengthened by the fact that the point of suspension was not 
the centre, but actually nearer the caudal extremity. It was obvious to 
those who refused to accept of this theory, that however it might be held 
as applicable to the first weeks of pregnancy, such a mechanism could 
have no share in producing or maintaining the presentation, after the 
cord had attained a length equal to the diameter of the ovum ; and, 
further, that, if the theory were correct, gravitation would be more 
likely to induce cephalic presentation in the early weeks of labor than 
at any other time. Every one knows, they argued, that, on the con- 
trary, it is not at the beginning, but at the end, of pregnancy, that this 
is most constantly observed, and, therefore, the idea in question is wrong. 
Dubois, who took a prominent position in opposing the gravitation theory, 
further disproved it by some interesting experiments, which he made by 
plunging the foetus in water, and suspending it by the umbilical cord, 
when he found that it was not the head, but the scapula, or back, which 
hung downwards, and first touched the bottom of the vessel. And to 
these arguments it might be added, that the placenta is not always 
attached to the fundus — which situation could alone admit of such gravi- 
tation ; and again, that, in the lower animals, the gravitation theory 
would place the head at the fundus, whereas, here also, we find the head 
turned to the os. In women, moreover, who maintain the horizontal 
position during the whole course of pregnancy, the cranial presentation 
is as constant as in other cases. 

An ingenious plea in favor of gravitation, as a cause of the ordinary 
presentation, has more recently been advanced by Dr. Matthews Duncan, 
who energetically controverts the opinions of Dubois, Simpson, and Scan- 



CAUSES OF CEPHALIC PRESENT ATTON . 127 

"zoni, and ^vho insists, "SNith mncVi propriety, that, in deciding this point, 
■\ve should always remember that, while the mother is in the erect pos- 
ture, or when she is lying on her back, the uterus is far from vertical ; 
that, on the contrary, it is only when the trunk is inclined backwards at 
an angle of 30° to the horizon, that the uterus can be said to be vertical; 
and that the mature foetus is only horizontal when the woman lies upon 
her side. Dr. Duncan's arguments are of too controversial a character 
to be usefully epitomized ; bat they must be referred to with the respect 
which they merit, and which they will always command. 

The name of Dubois is, in this particular matter, associated with a 
theory, the evidence in favor of which is, we must admit, singularly 
inconclusive. M. Dubois supposed that, in obedience to some instinctive 
impulse, or act of volition, certain movements were, towards the end of 
pregnancy, executed by the foetus, with the object of bringing the head 
into the lower segment of the uterus. This renowmed obstetrician de- 
rives his chief argument from the harmony which he believed to exist 
between the object which nature had in view, and the means w^hich she 
adopts, with a view" to secure it. It is more than likely that Dr. Tyler 
Smith is correct when he surmises that, "had he (Dubois) w^ritten after 
the reception of Dr. Marshall Hall's great discovery of the spinal or 
physical movements, as distinct from the cerebral or psychical motor 
actions of the animal economy, he would probably have referred the 
motor powers of the foetus to reflex action, instead of to instinct or 
volition." 

The late Sir James Y. Simpson, in a series of admirable papers on 
this subject, has attempted to prove that the presentation of the foetus is 
due, in the first instance, to a succession of reflex or "adaptive" move- 
ments, and that, when it has once assumed the usual presentation, it is 
maintained in it, when displacement is threatened, by a repetition of 
similar reflex acts, which rarely fail to insure its reposition. It is in 
this way, and on this principle, that violent foetal movements succeed 
such changes in the maternal posture as may lead to the displacement 
of the foetus; and he adds, further, that in cases of long cord, and in 
those in which the quantity of liquor amnii is much above the average, 
such movements on the part of the foetus are more frequent, and are of 
greater violence than usual. These last statements are certainly open to 
doubt. 

Cazeaux attaches great w^eight to the form of the uterus, as mechani- 
cally inducing the presentation of the foetus in the last months of preg- 
nancy, the broader or breech end of the foetal ovoid being necessarily 
turned towards the fundus, and the smaller, or cephalic end, consequently 
directed to the os. Some consider the child as composed of two ovals, 
one formed by the head, and the other by the trunk and limbs, and that, 
corresponding to these, the outline of the uterus is observed to consist of 
a portion of two ovals, as may be seen by looking again at Fig. 72. 

It must be remembered, however, with reference to these various theo- 
ries, that it is only in cases at the full term that the head presents in 9(3 
per cent. ; and, with regard to most of the observations w^iich have been 
made, that they have reference mainly to cases occurring at this period. 
It is universally admitted, that the earlier the period of the pregnancy, 
the less constant is the presentation of the child. The following table, 



128 



DEVELOPMENT OF THE EMBRYO AND FCETUS 



Period of pregnancy. 



Before end of sixth, month 

During seventh month 

During eighth and ninth month 
At full term of gestation 





Pi 


esentations 


of 


Total 
cases. 
















Shoulder. 


Breech. 


Head. 


121 


5 


52 


65 


119 


6 


31 


82 


96 


2 


22 


72 


103 


1 


3 


96 



Percentage of 

Head 
Presentations. 



52 in 100 

68 in 100 

76 in 100 

96 in 100 



founded upon the observations collected by Professor Dubois, at the 
Maternity Hospital of Paris, has been constructed by Simpson, and is, 
as he says, sufficient to prove " that the position (presentation?) of the 
foetus, with the head lowest, and over the os uteri, does not begin to be 
assumed till about the end of the sixth month, and that it is taken up with 
increasing frequency and certainty from that period onwards, to the full 
term of pregnancy." It must be noticed, however, with reference to 
this table, that, whereas the returns for the first, second, and fourth 
lines,, have reference to children born during the specified period, whether 
alive or dead, the figures in the third line, of children born during the 
eighth and ninth month, refer only to children born dead. 

The reason of the greater variety of presentation in the early months 
is sufficiently obvious. Not only is the child at this period smaller 
relatively to the cavity which is prepared for it, but the form of the 
cavity itself is such, as comparatively to encourage changes of the pre- 
sentation. Until the sixth month, the cavity of the cervix not having 
been as yet encroached upon, in the process of development, the child is 
contained in the body of the uterus. Most anatomists agree that, up to 
this period, this cavity is round, and not oval, so that, as in the annexed 

diagram (Fig. 78) a foetus of five 
months may move much more freely 
in any direction than is possible at 
the full time, when it is closely em- 
braced by the pyriform or ovoid 
womb. 

It must be confessed, however, 
that the causes which lead to the 
presentation of the head constitute a 
subject still shrouded in no little ob- 
scurity. The fact being clearly es- 
tablished, we see no need to pin our 
faith exclusively upon a single theory, 
particularly as it is more than proba- 
ble that most, if not all of them, point 
to individual causes which, acting 
successively, or in concert, produce 
the effect which we have been con- 
sidering. No theory quite satisfac- 
torily accounts for the fact that the 
embryo assumes its ovoid form at so early a date of development We 
know, of course, what Harvey first taught, that " all animals, while they 
are at rest or asleep, fold up their limbs in such a way as to form an 



Fig. 73. 




uterine Cavity at the Fifth Month. 



CAUSES OF CEPHALIC PRESEXT A TIOX . 129 

oval or globular figure." This has been ascribed by modern physiolo- 
gists to the greater muscular tone and contraction of the flexor as com- 
pared with the extensor muscles : but, dating from a period of develop- 
ment antecedent to the formation of muscles properly so called, it is 
questionable whether even this will throw much light upon the point in 
question. In regard to the theory of gravitation, as originally promul- 
gated, it is now sufficiently obvious that suspension by the cord cannot 
be the cause of the usual presentation at the end of pregnancy. It 
would be too much, however, to assume that gravity exercises no influ- 
ence upon the foetus ; indeed, the experiments of Matthews Duncan and 
Cazeaux point to a directly opposite conclusion. On the whole, however, 
we incline to the idea of reflex action, as affording the most reasonable 
theory which has yet been promulijated; but, far from shutting out the 
hypothesis of gravitation, we can conceive nothing more likely than that 
the vital force and the physical law act harmoniously together here, as 
elsewhere, at the bidding of nature. 

When the foetus is abnormally situated in the womb, the walls of this 
organ yield, and adapt themselves to the altered circumstances of the 
case. The bent posture is, however, always maintained, and the foetal 
ovoid is only distorted, in a marked degree, when the violent pressure 
of the contracting walls acts upon a misplaced foetus. It is in the ordi- 
nary presentation that the ovoid is most regular and marked — the larger 
pole being upwards, and occupying the expanded fundus, while the 
smaller is turned towards the vagina. If we take the longest, or bi-polar 
measurement of the ovoid, at 12 inches, the broadest part of the larger 
end, from the lumbar region to the sole or edge of the foot, will usually 
be found to be about 8 inches, and to correspond to the greatest trans- 
verse measurement of the cavity. Obviously, therefore, any marked 
alteration in the attitude or presentation of the child implies distortion of 
the outline of the womb. The fact of the smaller or cephalic end being 
only some 4J inches in its larger or occipito-frontal measurement, has led 
to the idea which has been frequently expressed, with reference to the 
mechanism of delivery, that the child thus placed was a wedge, and that 
the smaller end dilated the parts for the passage of the larger breech. 
Nothing can, in point of fact, be more erroneous than this, or more 
likely to lead to serious practical blunders. For we find that, when the 
pelvic end presents at the os, labor, far from being retarded, often ad- 
vances, up to a certain stage, with unusual ease and rapidity — a fact 
which is owing to the plastic nature of the structures of which it is com- 
posed. If the cephalic end were really a wedge, the head, or apex of 
the wedge, would never fail to follow the breech at once, and with ease. 
But as it does not, and is often extracted onlv after much sufferino;, and 
at great risk to the child, we cannot admit the simile to be a happy one. 
The fact is, that the smaller end of the ovoid is the really formidable 
structure in the act of partuntion, from its comparatively unyielding 
nature, due to the special means which are adopted for the protection of 
the important nervous centre, upon the integrity of which the life of the 
infant depends. "When the head has passed in safety, it is rarely, in- 
deed, that there is any difficulty in the birth of the other parts. To the 
obstetrician, therefore, one of the most important practical points in the 



130 DEVELOPMENT OF THE EMBRYO AND FCETUS. 

study of his art is the thorough comprehension of the foetal cranium, 
and more especially of its relation to the pelvis, and to the other maternal 
structures which have already been described. 

The Foetal Cranium. — The bones which compose the cranium and face 
are found, at the period of delivery, to have reached different stages of 
development. With a view, no doubt, to the perfect protection of the 
important organs at the base of the brain, the bones which form the base 
of the cranium, and the greater part of the face, are already so fused 
together as to admit of little or no movement. It is different, however, 
with the flat bones of the vault. The subjacent parts of the great ner- 
vous centre, being less essential to life, admit, with perfect impunity, of 
a certain amount of compression, which is facilitated by the imperfect 
ossification of the flat bones. The various parts of which the cranium is com- 
posed are, of course, familiar to every student of anatomy. It will suffice, 
therefore, to notice those points only which are of special obstetrical interest. 
The Sutures are, first, the sagittal^ which runs along the vertex, from 
the anterior to the posterior fontanelle. In continuation of this, there 
runs forward a suture, which is peculiar to early life, and which is 
described by some Avriters as a part of the sagittal suture. This, which 
divides the frontal bone into two equal parts, is usually named the frontal 
suture. The coronal suture marks the line of demarcation between the 
frontal and parietal bones ; while the lamhdoidal suture runs outwards 
and downwards, from the posterior fontanelle, separating, on either side, 
the posterior margin of the parietal from the occipital bone, and having 
thus the appearance of a bifurcation of the sagittal suture posteriorly, it 
presents some resemblance to the Greek letter from which it takes its 
name. At the base of each parietal is the suture which unites it to the 
corresponding temporal bone. 

The ossification of the bones, at all these points of contact, is so in- 
complete, as to admit of very considerable motion ; and in some situa- 
tions — as at the sagittal suture — the bones overlap each other to such an 
extent that, by reducing certain diameters, a great mechanical advantage 
accrues in the act of parturition. The angles of the bones are the points 
at which the development is least advanced, and it is here that certain 
gaps are left, where membrane only intervenes between the scalp and the 
brain, and through which the pulsations of the latter may be observed. 
These gaps are called the Fontanelles. The largest, the great or anterior 
fontanelle, or bregma (Fig. 74, c«), is irregularly 
lozenge-shaped, of considerable size, and easily 
recognized by the finger during labor. The larger 
portion of it is in front of the coronal suture, 
whence it is sometimes continued forwards, almost 
to the root of the nose. The posterior fontanelle 
(/>) is very much smaller, and is triangular in 
shape. As the occiput is almost always turned 
forwards, it is this fontanelle which the finger 
usually touches in an examination during labor ; 
but in well-developed crania, and more especially 
„ „ . f T, . , where overlappino; of the sutures has taken place, 

Upper feurfaco of Fcctal . >^^. & n n n • 

crauium. it scarccly mcrits the name oi a lontanelle, but is 




THE FCETAL CRANIUM, 



131 



rather a point at whicli the lambdoidal and sagittal sutures meet. 
In a digital examination, it is of importance that the accoucheur 
should be able at once to distinguish between these fontanelles, for 
it is mainly by marking their situation that he is enabled to recog- 
nize the exact position of the head. A.t first, the student will find some 
difficulty in ascertaining this, but a little care and attention will soon 
enable him to overcome the trifling difficulty ; and he will find it useful, 
when in doubt, to run his finger round the gap, and count the sutures 
which run into it: in the case of the anterior fontanelle, these are four 
in number, and, in that of the posterior, three only. The tumefaction of 
the scalp, w^hich is so common an occurrence in difficult labor, may 
render such an examination difficult ; but in the absence of this, the 
only circumstance which might mislead him, on a hurried examination, 
would be the presence of the irregular bones, called ossa triqiietra. 
Some writers describe lateral fontanelles at the inferior angles of the 
parietal bones, anteriorly and posteriorly ; but these are so covered in 
by the temporal muscles, that it is only under very exceptional circum- 
stances that their observation can be of any practical moment. 

It must now be obvious that a correct knowledge of the size of the 
cranium, and the relation w4iich it bears to the pelvis in its various 
diameters, must in no small measure be our guide to intelligent and 
skilful practice. Numerous measurements have been taken of the foetal 
cranium, for the most part between points arbitrarily selected. It is, 
however, only the most important of 
these diameters Avith which the memory 
need be charged, viz., the occipito- 
frontal^ the occijnto-mental, and the 
bi-parietal; and, in addition to these, 
"Nve shall mention only the traclielo- 
hregmatic and i\\Q froyito-mental. 

The Occipito-frontal, or long dia- 
meter of the oval cranium, is an 
imaginary line, extending from the 
frontal eminences, anteriorly to the 
occiput posteriorly. It is somewhat 
doubtful what some authors mean in 
this case by " the occiput," but there 
is no doubt that most modern writers, 

who are exact in the matter, describe it as terminating at the summit of 
the occiput, or, in other words, at the posterior fontanelle. If, during 
labor, the attitude of the head in relation to the trunk were the same as 
in an adult in the erect posture, this would doubtless be correct. But if 
we recall the fact that the chin of the child is applied to the sternum, 
and that the occiput passes into the pelvis considerably in advance of the 
forehead, it seems more correct to adopt the view of Cazeaux and some 
others, and draw our line (Fig. 75, a h) to the occipital protuberance. 
The actual measurement, it is true, is only fractionally greater, but the 
line indicated is certainly more nearly in coincidence with the plane of 
the pelvic brim and the upper part of the cavity, than that which is 
usually described. 




Diameters of the Foetal Cranium. 



132 DEVELOPMENT OF THE EMBRYO AND F(ETUS. 

The Occipito-raental is the largest of the cranial diameters, and exceeds 
that just described, if we make an allowance for an average amount of 
moulding, by about an inch. It is thus of great importance with refer- 
ence to the mechanism of parturition, and is represented in the figure by 
the line o m, drawn from the point of the chin to the posterior fontanelle. 
The Bi-parietal diameter (b 5, Fig. 74) extends transversely from one 
parietal protuberance to the other. The Trachelo-bregmatic (Fig. 75, 
^ ^), is from the posterior extremity of the anterior fontanelle, to the 
anterior margin of the foramen magnum; and the Fron to-mental, h m, 
from the level of the frontal eminences to the point of the chin. Most of 
these diameters will be increased or diminished in direct proportion to 
the amount of pressure to which the head is subjected, and the consequent 
degree of moulding which it undergoes. It is, on that account, extremely 
difficult to state averages ; and the recognized differences which subsist 
between male and female crania, not to speak of the varieties depending 
on race, still further increase the difficulty. Taking, however, the 
average of male and female crania in Europe, the following measurements 
probably come very near the truth — if at the same time we make due 
allowance for average moulding, which, if we are to estimate the size of 
crania at the moment of birth, must certainly be done. 

Average measurement of male and female Foetal Crania : — 

Occipito-frontal diameter ........ 4^ inclies 

Occipito-mental " . . . . . . . . 5^ " 

Bi-parietal " . 3^ " 

Trachelo-bregmatic " 3| " 

Fron to-mental " 3^ " 

It is scarcely necessary to add, that these measurements refer to cases 
in which the head is born in the occipito-anterior position. In other 
cases of abnormal or unusual position, the moulding will be modified to 
suit the requirements of the case, and the diameters will thereby be 
relatively altered. The same remark applies to circumferential measure- 
ments, which are usually stated, as regards the occipito-frontal circum- 
ference, as about fourteen inches, and for the occipito-mental as sixteen 
inches. According to Dr. Tyler Smith, " the ordinary presenting cir- 
cumference, which passes under the occiput, and round the parietal bones 
to a little behind the bregma, is about eleven and a half inches." 

In descriptions of foetal crania, and of cranial positions, the term 
"vertex" is constantly adopted by English and American writers. Un- 
fortunately, how^ever, this is one of several terms which are so loosely 
used, that it is necessary to give a definition before venturing to employ 
them. It is described in Todd's Cyclopaedia as synonymous with the 
anterior fontanelle; by Dr. Ramsbotham, as a point a little in front of 
the posterior fontanelle ; by Smellie, as the whole space between the two ; 
and by Schmidt, as a point midway between the anterior and posterior 
fontanelle. Of all these, the most usual description is that which places 
the vertex in or close to the posterior fontanelle. The expression " crown" 
or " vertex" implies that portion of the head which is highest in the erect 
posture. If so, the vertex can neither be the anterior nor posterior fon- 
tanelle, but a point intermediate between the two, varying somewhat 
according to the peculiar formation of diiferent crania, so that it is diffi- 



FUNCTIONS OF THE FOETUS. 133 

cult to determine the exact point. If it were absolutely necessary to 
describe it as such, we should probably closely approach the truth by 
placing it with Schmidt at a point midway between the two fontanelles. 
But if we consider the infinite varieties which obtain in the relative situa- 
tion of the two fontanelles, as regards the pelvic axes, so that any one 
point of the sagittal suture may in certain cases present, it then becomes 
obvious that to the term vertex we must attach a more extended significa- 
tion, if we would avoid complicated systems of classification. On these 
grounds we prefer the definition of Smellie, and shall use the term vertex 
as including the sagittal suture in its whole length, and on either side 
that portion of the parietal bone* (once called os verticis') which lies be- 
tween the suture and the protuberance. 

Functions of the Foetus. — The foetus being, during the whole period 
of its intra-uterine life, separated from the outer world, and immersed in 
a liquid medium, those functions which, after birth, are discharged under 
the usual atmospheric conditions, and in consonance with the ordinary 
laws of nutrition, fall to be performed after a fashion adapted to the 
peculiar circumstances of the case. We find, therefore, that, in the 
absence of aerial respiration, certain special modifications of the circula- 
tory apparatus have been adopted, with the view of aftbrding that gas to 
the blood, and that nutritive material to the frame, without which life 
within the womb would be a physical impossibility. A knowledge of 
this subject is essential both to the physiologist and to the accoucheur ; 
and it is only in the light of such knowledge that certain morbid phe- 
nomena and faults of development can be understood, and possibly, in 
some instances, obviated. 

The life of the foetus is maintained by an intimate union between the 
maternal and foetal circulatory systems, a union in which, although there 
is no junction of the two currents, there is ample provision for the mutual 
interpenetration of gases and fluids, and also for the interchange of cell 
elements. We do not allude now to the laws which regulate the develop- 
ment of the early embryo, but to the union which subsists after the 
development of the organs of connection which have already been de- 
scribed, and which exist in almost all the Mammalia. The lungs of the 
foetus are, up to the moment of birth, apparently rudimentary. We say 
" apparently," because, although in point of size and texture they pre- 
sent little resemblance to the organs of respiration, when that function 
has been once established, they are in the mature foetus already perfect 
in structure, and only await inflation to become the important organs, the 
function of which only ceases with life. In the adult, and dating from 
birth, the circulation is usually described as consisting of two tracts, 
mutually dependent upon, and yet in a sense distinct from, each other, 
the systemic and pulmonary channels, through which the whole column 
of blood continuously and successively flows. In the foetus, however, 
the function of the lungs being impossible, that portion of the circulatory 
current which is associated with the function of aerial respiration is 
diverted from its course by special conduits, which join the circuit at a 
more advanced point, the pulmonary system being thus practically nil., 
although its apparatus is fully prepared against the moment of birth. 
From the systemic vessels, again, blood passes to the placenta by the 



134 



DEVELOPMENT OF THE EMBRYO AND FCETUS. 



umbilical arteries, and returns by the umbilical vein to join the general 
venous system of the child. As the other functions of the foetus depend 
chiefly upon the modifications of what we know as the adult apparatus, 
we may here describe these shortly. 

The Foetal Circulation. — The blood which returns from the placenta 
by the umbilical vein (Fig. 76, c^) is charged 
with oxygen derived from the mother, so that 
the term "venous blood" is here, in its ordi- 
nary sense, inapplicable. After passing 
through the umbilicus, the vessel divides. 
A portion of its contents enters the liver, 
along with the blood which is being returned 
from the intestines by the vena portse (t/), 
and, after circulating in that organ, enters 
the vena cava at h. The greater portion of 
it, however, passes direct to the vena cava, 
by the ductus venosus (a), which joins the 
main trunk at a point a little lower than the 
hepatic vein. The blood, being thus mixed 
with the systemic venous current, arrives at 
the heart much more feebly oxygenated than 
it was at the umbilicus, and passing into the. 
right auricle, is directed by the Eustachian 
valve towards the foramen ovale, a special 
aperture through which the blood from the 
inferior cava is transmitted to the left auricle. 
From this point the current ])as3es to the left 
ventricle, and from thence, as in the adult, to 
tlie aorta, almost the whole of this supply 
proceeding to the head and superior extremi- 
ties by the three great vessels of the aortic 
arch, to return again to the right auricle by 
the superior cava. Although a mixture of 
the two currents from the venae cavse must, 
to some extent, inevitably occur, the blood of 
the superior vein passes, almost in its entirety, through the tricuspid valve 
into the right ventricle, and thence to the commencement of the pulmo- 
nary artery. The condition of the lungs not being such as to receive 
this laro-e column of blood, another special structure, the ductus arte- 
riosus (r) is interposed, through which the current is diverted, and con- 
ducted directly into the descending aorta. Along with a little blood from 
the left heart, this column passes downwards to the lower part of the 
body, most of it going to the placenta by the umbilical arteries, from 
whence, charged with oxygen, it again returns to the vena cava inferior. 
It will be observed that three special conduits thus exist; two of them, 
the foramen ovale and ductus arteriosus, being designed with the direct 
object of diverting the circulation from the lungs, while the other serves 
to connect the vena cava with the umbilical vein. In addition to these, 
which are completely obliterated after birth, there are the umbilical arte- 




Circulatory apparatus in the Foetus 



THE FCETAL CIRCULATION. 135 

ries, which are permanent in a portion of their course, forming the in- 
ternal iliac and superior vesical arteries. 

The Lungs enter upon their function immediately upon the birth of the 
child, and when anything occurs to prevent the speedy occurrence of the 
respiratory act, the child is still-born. The sudden inflation of the lungs 
which thus occurs, and the arrest of the placental circulation, consequent 
upon the separation of that organ from the mother, give rise to immediate 
changes in the direction of the current, which are the first steps in the 
obliteration of the special foetal structures which have been described. 
The essential phenomenon is the transference of the seat of respiration 
from the placenta to the lungs. By the consequent development or un- 
folding of the pulmonary vessels, a vacuum is created, which draws the 
blood from the right ventricle directly, and for the first time, into the 
pulmonary circuit. The aorta, lacking thus the important source of 
supply which it had hitherto derived from the ductus arteriosus, sends a 
diminished supply of blood in a feeble stream to the umbilical arteries, 
thus encouraging the stasis of the blood in the foetal portion of the pla- 
centa. This causes a marked diminution, and soon a complete cessa- 
tion, of the flow of blood through the umbilical vessels. When the left 
auricle is sufficiently supplied, by the return of the blood from the lungs 
through the pulmonary veins, the foramen ovale is closed by the pressure 
of the blood upon its valve, the closure being further encouraged by the 
diminution in the supply of blood to the right auricle, which is the neces- 
sary result of the arrested circulation in the umbilical vein. These facts 
make it clear how important it is for the mechanism of the circulation, 
that the establishment of aerial respiration should be simultaneous with 
the arrest of the placental circulation. It is only upon the complete 
establishment of the pulmonary circulation, that the distinction between 
arterial and venous blood can, with perfect propriety, be drawn. There 
is no longer a mingling of the two currents, and they now assume within 
their proper vessels the physical characteristics which serve to distinguish 
them. 

The time at which the obliteration of the foetal apertures takes place, 
and the order in which they close, are facts of some medico-legal import- 
ance. Effective closure, if not obliteration, of all of them, will generally 
be found to have occurred by the ninth day, although they may remain 
patent for twelve or fifteen days, or even longer, without any inconve- 
nience to the child. The umbilical arteries are usually impermeable from 
the second day, owing to contraction and thickening of their walls ; the 
umbilical vein and ductus venosus always close after the arteries, gene- 
rally about the sixth or seventh day. The ductus arteriosus and foramen 
ovale are the last to be obliterated, but rarely remain permeable longer 
than the period above stated. In regard to the latter, it has been said 
that, whil'e it is the last to close, it is the first to contract. In the em- 
bryo, there is but one auricular cavity : but, about the third month, a 
semilunar valve, containing fleshy fibres, marks the first growth of the 
partition which ultimately separates the right from the left auricle. 
Permanence of the aperture may constitute the affection known as Cya- 
nosis. Dr. Tyler Smith is of opinion that the closure of the foetal aper- 
tures is, in a great measure, due to the mechanical eff"ect of the inflation 



136 DEVELOPMENT OF THE EMBRYO AND FCETUS. 

of the lungs; and there can be little doubt, we believe, that this contri- 
butes to the result, by the pressure which is exercised, in one direction, 
by the left bronchus, upon the ductus arteriosus, and, in the other, by 
the displacement downwards of the liver, upon the umbilical vein and 
ductus venosus. The changed position of the heart also tends to the 
closure of the foramen ovale. Another very marked result of the altera- 
tion in the circulating system, — one which acts somewhat more slowly, — 
is the thickening of the walls, and augmentation in the capacity, of the 
left heart, which, prior to birth, is subordinate to the right heart in both 
of these particulars. In three or four weeks this change is very ob- 
vious. 

The blood of the mature foetus does not differ materially from that 
which occupies the vessels after birth ; but, owing, no doubt, to the com- 
paratively imperfect oxidation which takes place in the placenta, and the 
manner in which the two systems mingle, there is not observed that con- 
trast in color which enables us to distinguish arterial from venous blood. 
As regards the blood of early embryonic life, few opportunities occur in 
which it can be examined ; but, from what has been observed, it would 
appear that it is of a dark color, coagulates feebly, is deficient in fibrine, 
and becomes but little reddened on exposure to the atmosphere. 

Mespiratio7i. — From what has just been said, in reference to the course 
of the circulation of the blood in the foetus, it will be obvious that the 
respiratory function must be carried on in the placenta, — the most impor- 
tant of whose functions, indeed, is that of an intra-uterine lung. We 
need not pause here to discuss exploded theories, as to the source from 
which oxygen is derived by the foetus. The researches of Bischoff 
proved that, even in the embryo, respiration by means of the branchial 
fissures is impossible, and that, in point of fact, these structures have no 
connection whatever with this function, as was at one time erroneously 
supposed by GeoS'roy Saint-Hilaire and others. Tavo facts stand out 
prominently : first, that a constant supply of oxygen is necessary to the 
life of the foetus ; and, second, that that supply cannot be obtained di- 
rectly from the air. Whence, then, is it derived? 

The full description, which was given in a former chapter, of the 
structure of the placenta, may suffice for an answer to this question, in 
so far as regards that period of intra-uterine life during which the pla- 
centa exists. But, for the period of embryonic life, some further descrip- 
tion is required ; and, indeed, there is still, in regard to this point, some 
necessity for extended research. M. Serres has described two periods, — 
the first of these, which he terms the period of branchial respiration, 
exists down to the time when the placenta is formed. He assumes that, 
among the villi of the chorion, there are a certain number (yillosites 
hrancJiiales) which dip into the lacunae of the decidua reflexa, and are 
there bathed in a special fluid, from which the supply of oxygen is de- 
rived until, in the coarse of development, the second, or placental period, 
arrives. To what extent, if at all, this theory may be admitted as cor- 
rect, it is at present impossible to determine ; nor would it serve any 
good purpose to enter here upon the discussion of this or any mere 
physiological speculation. We shall at once, therefore, assume, as facts 
hitherto observed entitle us, that from the earliest period at which the 



NUTRITION OF THE FOETUS. 137 

necessity of a respiratory function may arise, the essential supply of 
oxygen is derived from the mother, and passes through the external sur- 
face of the ovum, the villi of the chorion, or the villi of the placenta, 
according to the stage of actual development. The function of respira- 
tion involves the interchange of gases ; but whether this interchange 
takes place in consonance with- the laws which regulate interpenetration 
of fluids, or by passing through some intermediate vehicle, as is pre- 
sumed by Serres, the source of the supply may, in all cases, be assumed 
to be the same. In point of fact, the respiration- of the foetus bears the 
strictest analogy to the branchial respiration of fishes, in which a mem- 
branous structure only is interposed between the blood and the liquid 
from which the oxygen is to be derived. In the placenta, as w^e have 
seen, the parts are so disposed as to bring as large a portion as possible 
of the two systems, maternal and foetal, into contact. 

That, in consequence of this contact, the blood undergoes important 
and vital changes is proved by many facts, pathological and otherwise. 
To compress the cord, is to cause the certain death of the foetus ; but 
more significant even than this is the fact, that after death from this 
cause, the physiological phenomena of apnoea are invariably developed. 
There exists, also, a marked respiratory antagonism between the placenta 
and the lungs. So long as the placental circulation is still uninterrupted, 
the new-born infant may live Avithout pulmonary respiration ; but so soon 
as it breathes strongly, the blood no longer passes by the cord, or if it 
persists to a certain extent, it may at once be stopped by ligature. But 
if the child has not breathed, it is always wrong to tie a pulsating cord 
until aerial respiration has been set up. Finally, the respiratory function 
of the placenta has been proved by analysis of the blood from the um- 
bilical arteries and veins, the blood in the vein always showing a com- 
parative abundance of oxygen, although, as already mentioned, the 
quantity of this gas is not sufficient to establish that marked difi"erence 
in color which enables us so readily to distinguish between ordinary 
arterial and venous blood. 

Nutrition. — This function is intimately associated with that of respira- 
tion. All modern physiologists admit that the nutritive supply comes 
from the mother, but the exact manner in which it is absorbed, and the 
proportion in which it passes through various channels and media are 
points which have given rise to endless disputes, and many hypotheses. 
It is certain that the nutritive material cannot, at all stages of embryonic 
and foetal development, pass through the same course in its way from 
mother to child ; and, in truth, our knowledge of the history of develop- 
ment prepares us for the admission that the plan of nutrition must differ 
materially according to the stage at which the fertilized ovum has arrived. 
Even at the very earliest stage, while it still moves freely in the Fal- 
lopian tube, absorption from maternal sources may take place by endos- 
mose through its external envelopes, which also admit of penetration by 
the fertilizing sperm of the male. But, in addition to this, there is a 
store of material, which we have reason to believe is in a great measure 
nutritive, contained in the umbilical vesicle. The quantity of this, and 
the proportion which it bears to the size of the embryo, is at first very 
great, but as changes succeed each other within the ovum, in the manner 



138 DEVELOPMENT OF THE EMBRYO AND FCETUS. 

already described under the head of Developraent, the relative quantity 
dwindles, and the reservoir itself becomes ultimately absorbed, after 
being drained of its contents. The connection of the umbilical vesicle 
with the rudimentary intestine, the chemical composition of its contents, 
and, more significant still, the establishment in its walls of bloodvessels 
proceeding from the foetus, suffice to prove this position. After the de- 
velopment of the allantois, vessels are carried from the embryo to the 
chorion ; the villi of the latter become enlarged and vascular, implant 
themselves in the decidua, and thus bring foetal vessels and foetal blood 
into the closest contact with the mother. Some have even believed 
that the villi plunge into the tubular follicles, and thence derive their 
pabulum. 

With the formation of the placenta, this contact becomes localized, and 
at the same time, owing to the peculiar structure of that organ, is greatly 
increased m extent. Through the delicate membranes which separate 
the one system from the other, and in addition to the gaseous supply 
which constitutes the respiratory function of the placenta, there pass in- 
cessantly, in fluid form, materials Avhich go to the building up of the 
foetal tissues. But it is not alone by a mere endosmose, or by mutual 
interpenetration, that this nutritive function is carried on, but by a pro- 
cess of intermediate cell-growth, in the course of Avhich materials are 
elaborated, with the express object of foetal nutrition. Goodsir's theory 
on this point is illustrated by the accompanying diagram (Fig. 77). His 
observations led him to the conclusion that the 
Fig- '^*^- blood in the vessels of the mother is separated 

from that in the vessels of the foetus, by the in- 
tervention of two distinct sets of nucleated cells. 
One of these, e, belongs to the maternal portion 
of the placenta, lies in contact with, and external 
to the ultimate maternal vessels, and is probably 
designed for the separation from the blood of the 
V^ mother of the materials destined for the foetus. 

Diagram uiustrating Good- r^^^ Q^^^gj. layer,/', Ucs bctwcen the membrane of 
tri^ion. ^*^'^ "^ ^ ^ ''' the foetal villus and the wall of the vascular loop 
which it contains, the object of these cells being 
to receive the material which has been elaborated on the other side. 
Between the two there is a space, d, into which the materials secreted 
by one set of cells is poured, in order that it may be absorbed by the 
other. In this way, it is probable that not only are materials passed 
from the mother to the foetus, but that, through the same agency, efiete 
or excrementitious matters are transferred from the foetal to the maternal 
blood. 

Another source from which nutriment may be drawn is the liquor 
amnii. Substances introduced into the stomach or blood of the female 
have been found in this medium, as well as in the foetus and placenta, 
and its analysis has proved it to contain albumen, osmazome, and salts. 
Besides this, newly born calves have been kept alive by fresh amnionic 
fluid during a period of fifteen days. This being the case, it has been 
assumed by some that nutritive material passes by this channel from the 
mother to the foetus. The mammary glands, the genital organs, and the 




SECRETIONS OF THE FCETUS. 139 

alimentary canal have all been upheld as constituting the mediate channel 
of communication; but there can be little doubt that such communication, 
if it occur at all, is most likely to take place through the entire cutaneous 
surface. This idea is confirmed in an especial manner by the observa- 
tions of Brugmans, who found, on removing the embryo from the amnionic 
pouch in living animals, that the lymphatic vessels of the skin were in 
an engorged condition, while those of the intestines, the functions of 
"which had yet to be established, were found to be empty. If we admit 
that these facts establish the belief of nutrition through the liquor amnii, 
we see no reason to doubt what Scanzoni asserts, that a similar absorp- 
tion may take place through the walls of the umbilical cord, and that 
this would be a more direct way than any to the main channel of the 
foetal circulation. Beyond all doubt, however, the main source of nutri- 
tive supply to the foetus is the placenta, while the liquor amnii may be 
looked upon as an auxiliary medium, through which, possibly, certain 
special elements may be admitted. 

Secrttions. — The secretions of the foetus are similar in their nature to 
those which are found after independent existence has been established, 
but are, according to the period of development, in a more or less rudi- 
mentary condition. It is necessary to mention here three only, the Bile, 
the Urine, and the Meconium. 

The Liver is, in proportion to the size of the foetus, and in comparison 
with the same organ in adult life, a viscus of great size. Prior to the 
fifth month, its structure is soft and pulpy, and the gall-bladder has the 
appearance of a white cord ; but about this period the secretion of the 
bile commences, the characteristic structure of the liver becomes devel- 
oped, and the gall-bladder begins to distend. It was long supposed that 
the chief function of the liver at this time was the separation of the 
hydro-carbonaceous portion of the protein compounds, but it is now be- 
lieved that this is mainly, if not solely, effected in the placenta. Ac- 
cording to Claude Bernard, sugar is found in the foetal structures in a 
larger proportion than after birth, even before the formation of the liver, 
but after the organ is developed there can be no doubt that its glycogenic 
function is one of its most important offices. At the end of the seventh 
month, bile makes its way into the intestine, and the gall-bladder is 
usually found distended with bile. 

The name mecoyiium is that which has been given to the excremental 
materials which are contained in the alimentary canal of the foetus. Up 
to the third month, the inner surface of the canal presents a slight 
moisture, but about this period the stomach and duodenum contain a 
small quantity of whitish albuminous fiuid. At the beginning of the 
sixth month, the contents of the small intestine will be found to have 
assumed a deep yellow color, owing to the admixture of bile, whicti 
gradually becomes darker in hue as pregnancy advances. The meconium 
now enters the great intestine, and ultimately, about the end of the term, 
occupies the rectum in considerable quantity, from whence it is ejected 
in presentations of the breech, and under various other circumstances 
which need not be here detailed. The meconium, then, is the result of 
a mixture of foetal bile with the material secreted by the mucous mem- 
brane of the digestive canal. 



140 PREGNANCY. 

The Urine is secreted at an early period of intra-uterine life, when 
the structure of the kidneys is already very considerably advanced. It 
was at one time supposed that the bladder communicated directly, by 
the urachus, with a cavity in the allantois, which thus constituted a 
reservoir for the urine. The allantois, however, in man at least, no 
longer exists as a cavity at the period when the kidneys form and the 
secretion of urine begins, so that we are forced to believe either that the 
quantity of urine excreted during intra-uterine life is not in excess of 
the capacity of the bladder, or that the surplus is discharged into the 
amnionic cavity. That the latter occurs, at least exceptionally, is proved 
by the discovery of urinary materials in the liquor amnii ; but, on the 
other hand, the existence of imperforate urethra, without any undue dis- 
tension of the bladder, proves that a periodical discharge of urine is not 
essential, and establishes the presumption that, as a rule, no such dis- 
charge occurs. 



CHAPTEE yill. 

PREGNANCY: SIGNS OF PREGNANCY. 

Pkegnancy. — The Gravid Uterus: Muscular fihres of: Muscular layers. — 
Change in fibres after delivery. — Development and anatomical relations of 
Uterus at various stages of Pregnancy. — Signs of Pregnancy. — Suppression 
of the Catamenia. — Digestive disorders : Morning Sickness : Salioaiion. — 
Kyesteine. — Changes in the Mammce : Pain: Enlargement : Secretion of Milk : 
Areola : Changes in Nipple^ and in Glandular Follicles : Secondary Areola. 
— Enlargement and external appearance of Abdomen : Flattening in early 
months : Change in the appearance of Umbilicus. — Diagnosis of other Abdo- 
minal Tumors. — Vaginal Examination: Color of mucous membrane : Vaginal 
Pulse. 

While the ovum undergoes, in the progress of its development, the 
changes which have been detailed, the organism of the mother is also the 
seat of important anatomical changes and physiological phenomena. 
Among these, the changes which occur in the uterus naturally attract 
very considerable attention. 

The Gravid Uterus, when we compare it with the unimpregnated organ, 
presents alterations, not only in magnitude, but in structure. Nothing 
could be more erroneous than the idea of the old physiologists that its 
development was a mere distension, similar to what takes place when we 
inflate an India-rubber bottle. There is, on the contrary, an increase 
in the quantity of its tissue, whereby its weight is progressively increased 
up to the end of pregnancy ; and there is, moreover, an alteration in the 
tissues of which it is composed, raising its structure, so to speak, to a 
higher physiological level. The changes which the mucous membrane 



THE GRAVID UTERUS, 



141 



undergoes have already been incidentally 
referred to in connection with the formation 
of the decidua. In regard to the tissue 
proper of the uterus, we have found it, in 
the unimpregnated state, to be composed 
of interlacing fibres, which are somewhat 
irregularly disposed. Had no opportunity 
ever existed of examining them in a gravid 
womb, it would perhaps have been held a 
bold speculation to maintain that these 
fibres are muscular elements of the non- 
striated variety. In the present state of 
histological science, nothing is more clearly 
demonstrated than that this is the case, 
even if the expulsive contractions of the 
uterus had not pointed to a similar conclu- 
sion. This is indicated with great distinct- 
ness in the accompanying illustration, where 
«,a, are nucleated fibre-cells from the un- 
impregnated uterus. Their embryonic or 
undeveloped condition shows in marked 
contrast with cells from the gravid uterus, 
which are shown in /), h, c^ c, and ^, at differ- 
ent stages of development. 

These fibres, which constitute so large a 
portion of the bulk of the womb, have, 
from the time of Vesalius, been described 
by anatomists as forming layers ; but the 
contradictory statements made on this sub- 
ject by the earliest anatomists, serve to 
show what may very easily be seen by ex- 
amining the uterus for ourselves, that the 
fibres are far from being regular and dis- 
tinct in their course. This is more espe- 
cially the case with regard to the unim- 
pregnated uterus ; but w^hen conception has 
occurred, and the fibres have reached the 
higher stage of devolopment figured above, 
not only are the fibres themselves more 
distinct, but their disposition in layers be- 
comes more apparent. It must be confessed, 
however, that not even the careful dissec- 
tions of Hunter and Madame Boivin, nor 
the microscopic researches of Kolliker,have 
as yet clearly demonstrated what is the ex- 
act arrangement of these layers. It may 
be asserted, no doubt, in general terms, 
that the fibres are irre.2;u]arly disposed, in 
this as in the other hollow viscera, so as to 



hfi. 



i 



Fibre-cells of tlie Unimpregnated and 
Gravid Uterus contrasted. 



142 



PREGNANCY. 



Fiff. 79. 




External Muscular Layer of Uteru 



form an external or longitudinal, and an internal or circular group ; but 
^vhen Ave come back to look at the actual drawings upon which these state- 
ments are based, we cannot fail to be struck with the fact that, as regards 
the outer layer, a very small proportion only of the fibres can be truly 

described as longitudinal. The accompa- 
nying cut (Fig. 79) shows the posterior 
surface of the uterus, from which the peri- 
toneum has been carefully removed, so as 
to exhibit the external layer of the muscu- 
lar tissue. It will be observed that the 
fibres appear to proceed from the sides of 
the uterus, where they are continuous with 
those which pass along the round ligament, 
the broad ligament, the ligament of the 
ovary and the Fallopian tube. Their di- 
rection therefore is, in the main, transverse, 
and when they reach the middle line some 
of them pass across, interlacing with their 
fellows of the other side ; while a certain 
number, according to Cazaux,turn upwards 
and downwards, after interlacing, to form the band of longitudinal fibres 
which is shown in the figure, and which is continuous with numerous pow- 
erful bundles passing over the fundus. A somewhat similar disposition 
is seen on the anterior surface. 

The inner layer, as described by William Hunter, and before him, 
though much less accurately, by Ruysch, is that which corresponds to the 
circular layer of the other viscera. It is thin, and composed of groups 
of fibres, the general direction of which is transverse, but arranged at 
either angle of the uterus, in a concentric manner, around the orifices of 

the Fallopian tubes, as shown in Fig. 80. 
Other groups encircle the middle of the body 
of the uterus, while others again are described 
as forming a sort of sphincter surrounding 
the OS uteri. Between these two layers, a 
third or middle layer is generally described 
by modern anatomists, as being of consider- 
able strength and thickness, with numerous 
bundles, flattened, and running in all direc- 
tions in the substance of the organ. These 
interlace freely, and surround the vessels of 
the uterus, so that, when the organ is in a 
state of contraction, these vessels must be 
notably diminished in their calibre. Indeed, 
there is every reason to believe that it is 
mainly by their agency that hemorrhage is 
prevented after the separation of the placenta, the ruptured and gaping 
orifices of the utero-placental vessels being thereby closed. 

Inseparably connected with the subject which we are now considering, 
is that of the involution of the uterus, or that process whereby the organ 
returns, after delivery, to a size and structure approaching that of the 




Internal Muscular Layer of Uterus 



INVOLUTION OF UTERUS. 



143 



unimpregnatecl state. That the uterus, in a short time, is reduced in 
weight, from about twenty-four ounces to two, involves the certainty that 
rapid absorption takes place under very special conditions. How this 
takes place has been indicated by many physiologists, but by none has it 
been demonstrated so clearly as by Kcilliker. The enormous fibre-cells 
which exist at the termination of pregnancy, are now huddled together 
in contraction, and, their function being over, absorption takes place, 
under favorable conditions, with great rapidity. They become the seat 
of rapid atrophy and fatty degeneration, and the whole mass of the mus- 
cular tissue becomes soft and friable. The separation of individual fibres 
for microscopic examination is, on this account, not easy ; but if success- 
fully removed, they will be found as represented 
in Fig. 81, where the appearance presented by 
them a fortnight after delivery is shown at a. 
About the fourth Aveek, the development of new 
fibres in various stages, ?>, may also be observed. 
A large portion of the fatty and disintegrated 
matter is removed by the vagina in the lochial 
discharge ; and a proportion still larger is pro- 
bably absorbed into the circulation, and dis- 
charged ultimately from the system by the 
ordinary excretory channels. The latter has 
been supposed to contribute to the formation of 
the caseous matter in the milk first secreted. 

That portion of the peritoneum which invests 
the uterus and neighboring parts, is evidently 
so disposed in the unimpregnated state, as to 
admit of free extension during pregnancy. It 
is in this way that the broad, as well as the an- 
terior and posterior ligaments unfold themselves, 
as the uterus slowly develops, until, at last, they 
entirely disappear. But it is not by a mere 
mechanical process such as this, that the serous 
covering of the womb adapts itself to the exigencies of the pregnant state, 
but, in addition, by an actual hypertrophy of its tissue. "Were the former 
alone the case, the extension thus furnished would not be possible with- 
out thinning of the membrane ; but as we invariably find that, at the 
very end of pregnancy, the membrane in question is as thick as before, 
we infer, that in this case as in large hernise and certain other morbid 
conditions, the serous, as well as the muscular and mucous coats of the 
womb, undergo marked hypertrophy. 

The development of the ovum within the womb, the various stages of 
w^hich w^e have traced, is necessarily accompanied by a corresponding in- 
crease in the volume of the uterus, and by marked changes in its ana- 
tomical relations. In the shape of the organ there is, from the first weeks, 
a marked alteration in respect of the antero-posterior flattening ; and, as 
the pregnancy advances, the general form approaches more a spheroidal 
than a pear shape. From the twelfth to the twenty-fourth week, the 
cavity assumes more and more of a rounded appearance, but still retain- 
ing a certain amount of the antero-posterior flattening, and its length is 




Degeneration of Fibre-CeUs 
after Delivery. 



144 



PREGNANCY 



Fig;. 82. 




Diagram showing Development of Uterine Cavity. 
Af.er Scbultze. 



also somewhat greater than its wic'th ; but, speaking in general terms, 
the cavity of the uterus may, at the last-named period, be described, as 

it is shown in the diagram (Fig. 
82), as globular. During the 
remaining sixteen weeks of ges- 
tation, the rounded shape of the 
uterine cavity becomes changed 
into an oval, so that at the end 
of pregnancy the womb is about 
twelve inches long, nine broad, 
and eight from before backwards. 
This change was formerly be- 
lieved to be effected in all cases 
by a progressive invasion of the 
canal of the cervix from above 
downwards. The numbers 30, 
36, and 40 are thus supposed to 
represent, by the dotted lines, the 
extent to which, at these weeks, 
the uterine cavity has increased 
at the expense of the cervix. The 
crosses, mark upon the uterine 
wall the site of the original os 
internum. To this subject, and 
more particularly to the state of 
the OS and cervix as a sign of pregnancy, we shall revert. 

These alterations in the form of the uterus, must needs be accompanied 
by changes, no less marked, in its situation and anatomical relations. 
During the first twelve weeks of gestation, the womb remains within the 
true pelvis, or cannot, at least, be felt above the pubes, although, on 
pressing the fingers somewhat deeply, it may be readily discovered. 
Seeing that the fundus is originally very near the level of the brim, it 
follows that the considerable increase in bulk which these weeks bring 
must find room in another direction. We find, therefore, that the de- 
velopment, under the circumstances, goes on in a downward direction, 
and that the os and cervix are discovered, on examination, to be much 
nearer the floor of the pelvis than they were before impregnation. It 
thus obeys, so far, the laws of gravity, and the weight of the intestines 
resting upon the fundus may, in some measure, contribute to the result. 
The progress of foetal growth soon renders it impossible for the uterus 
and its contents to remain longer within the pelvis ; and if, under pecu- 
liar circumstances, it is retained there, the safety, both of mother and 
child, is immediately endangered. 

In the course of the fourth month, the fundus can usually be felt by 
the finger of the accoucheur, above the pubes. The level which it 
attains at various periods of pregnancy depends upon the condition of 
the abdominal walls, and upon many other circumstances which render 
exact statements upon this subject impossible. Very generally, it will 
be found to have attained the level of the umbilicus some time in the 
course of the sixth month. About the thirty-sixth or thirty-seventh 



THE UTERUS DURING PREGNANCY. 145 

week it reaches the level of the xiphoid cartilage ; but between this time 
and the end of pregnancy, it falls downwards and forwards, preparatory 
to the phenomena of parturition. 

In rising from the pelvis, and going through the succeeding stages of 
its development, it is easy to understand how the uterus, with a tendency 
towards the right side, even in the unimpregnated state, will be still more 
encouraged in its movement in that direction, by the prominence of the 
vertebral column in the middle line.^ If we reflect further that the line 
which represents the axis of the uterus, is nearly coincident with the 
axis of the brim of the pelvis, and remember the marked projection of 
the lumbar vertebrae, we shall have no difl5culty in appreciating the 
causes which lead to the uterus being in immediate contact with the ante- 
rior abdominal wall, so that it is a rare occurrence when we find any 
portion of the intestines intervening between the abdominal and uterine 
walls in this situation. At- the termination of pregnancy, then, the 
uterus, with the ovaries. Fallopian tubes, and other structures closely 
applied to its side, occupies a great part of the abdominal cavity. Its 
usual relations are as follows: in front with the vagina, the neck and 
posterior wall of the bladder, and the anterior abdominal wall ; behind, 
with the rectum and the promontory of the sacrum below, and the mesen- 
tery and the intestines above ; on the right, by the coecum and the right 
abdominal wall ; and, on the left, by the sigmoid flexure of the colon, 
and, usually, the great bulk of the small intestines. 

Signs of Pregnancy. — The development of the womb, and that, 
already described, of the germ which it contains, constitute the essential 
anatomical and physiological phenomena of the pregnant state. Asso- 
ciated with it, however, and dependent upon its continuance, are numerous 
other manifestations, which hav^e their seat in organs so remote, that it 
is difficult, in many cases, to trace the sympathy which exists between 
them and the special organs of generation. There is, in point of fact, 
no single function of the whole economy which may not be aff'ected by 
the operation of a cause which has its centre in the generative organs, 
and which radiates thence throughout the entire system. Consequently, 
phenomena are frequently observed in distant organs which are certainly 
not associated in function with the womb ; but so constant is the occur- 
rence of these phenomena, that they have come to be familiarly looked 
upon as among the early symptoms of pregnancy. More important are 
the symptoms which have their cause and seat in the generative organs ; 
but in the observation even of these, there are, as in the case of the 
others, so many sources of fallacy, so many pitfalls of error, that obstet- 
rical writers have uniformly, and with obvious propriety, made a study 
of the Signs of Pregnancy, — one of the most prominent subjects to which 
it is desirable that the attention of the student in this department should 
be draAvn. We can conceive no subject in regard to which a mistake 

1 It has been held among other causes which hare been advanced to account for 
this displacement to the right, that the weight of the placenta gave rise to it, — it 
being more frequently, according to Levret, on the right side. The presence of the 
descending colon on the left, the habitual use of the right hand in preference to the 
left, and the habit of lying on the right side during sleep, are a few among the many 
reasons which have been propounded to account for the phenomenon. 
10 



146 PREGNANCY. 

mio;bt so utterly ruin a young man's hopes, than the determination, in 
delicate or doubtful cases, of this question of pregnancy. An obvious 
pregnancy overlooked, because the idea has never crossed the mind, is 
bad enough ; and we have known a practitioner of thirty years' standing 
blister the abdomen in the ninth month, under the idea that he was 
treating a morbid growth. But what is far more inexcusable, is the 
culpable rashness of those who, without irrefragable evidence of the 
existence of pregnancy, would venture — as has been done in high quar- 
ters — to brand a woman with the stigma of dishonor. To enable the 
practitioner to avoid these, and similar errors, the symptoms which indi- 
cate pregnancy have been arranged, with a view, more especially, of 
assigning to each its actual diagnostic value, and determining the period 
at which, in the course of a pregnancy, it is available. We shall find 
that the number of symptoms which are of themselves conclusive as evi- 
dence of pregnancy is very limited ; but the other, and more numerous 
group, constitute an important chain of circumstantial or corroborative 
links, which, under ordinary circumstances, enable us to admit the 
strongest probability of an event which may be either dreaded or longed 
for. The convictions of a woman whose most earnest desire is to be a 
mother, and the passionate asseverations of another whose chastity is 
called in question, are disturbing elements which tend to throw us out in 
our calculations, and must always be taken c^im grano. 

In classifying the Signs of Pregnancy, various plans have been 
adopted, but what seems more rational, and what certainly is much more 
satisfactory than any attempt at rigid classification, is to take up the 
symptoms, as nearly as may be, in the order in which they are mani- 
fested. The earliest of all the symptoms have their seat in the genera- 
tive organs, but are of little value from a practical point of view, inas- 
much as they consist in physiological and anatomical manifestations 
which are almost entirely beyond our ken. It is certain that the fer- 
tilized ovum, on its arrival within the cavity of the uterus, finds that 
organ in a condition suitable for its reception. Probably, the conditions 
which Ave have seen to exist, in ordinary healthy menstruation, as re- 
gards the tissues of the womb, are, under the special circumstances of 
conception, prolonged, and ultimately pass, by a series of developmental 
changes, some of which have been described, into those which are charac- 
teristic of the more advanced stages of pregnancy. Or, supposing even 
the uterus to be quiescent, and not under the influence either of a past or 
of an impending menstrual molimen, we niay assume that one of the 
earliest effects of impregnation is a marked congestion and hypertrophy 
of all the uterine structures ; changes which, though easily enough 
demonstrated after death, are not so easily appreciated during life, and 
are in reality of little actual diagnostic value. Still, the increased 
weight and heat of the uterus, the increased resistance in the upper and 
anterior wall of the vagina — due, it has been said, to a slight anteversion 
of the womb usual at this period — may, along with other symptoms, 
excite in the mind of the experienced practitioner suspicions which, under 
other circumstances, might not have arisen. 

Suppressioyi of the Catamenia is generally the first symptom which 
attracts the attention of a woman who admits to herself the possibility of 



EARLY SIGNS OF PREGNANCY. 147 

impregnation. Although this unrloubtedlj is a remarkably constant 
occurrence, it is by no means invariable. It has, hoAvever, a special 
interest, apart from its value as a sign of pregnancy, in the fact that it 
is from the last appearance of the menstrual flow that women are in the 
habit of calculating the period at which the birth of a mature child will 
probably take place. What detracts more especially from its value as 
an evidence of impregnation, are the remarkable aberrations which, 
under such circumstances, not unfrequently occur. It is far from being 
a very uncommon occurrence that, during the early months of pregnancy, 
the catamenia, or at least a periodical sanguineous discharge, makes its 
appearance much as usual. Cases in which this occurs up to the fifth or 
sixth month, are of much less frequent occurrence ; and fewer still are 
the instances in which, from the beginning to the end of pregnancy, the 
menstrual discharge apparently goes on as usual. Probably, Moreau is 
correct in assuming that, in these cases, the source of the discharge is 
not the same as in the ordinary menstruation ; but, as regards the im- 
port of the symptom, this is a mere speculation, and of no practical sig- 
nificance. Cases are on record also in which women menstruated only 
during pregnancy, menstruated for the first time after impregnation had 
taken place, or became pregnant without ever having menstruated at all. 
The last case, which is extremly rare, is analogous to what takes place 
in those instances in which Avomen who are nursing again become preg- 
nant, without ever having menstruated since the previous accouchement. 
The converse of these cases, and what goes still further to lessen the 
value of the suppression of the catamenia as a sign of pregnancy, is to 
be found in the very numerous examples which occur in every-day prac- 
tice, of patients in whom the discharge is suppressed, as the result of 
certain morbid conditions affecting, more or less directly, the generative 
organs. A similar result may obtain, and that even more frequently, in 
those instances in which the suppression is the result of constitutional 
causes, in themselves apparently quite independent of the generative 
functions. And, in a few rare cases, there is a suppression of the men- 
strual discharge without any appreciable cause, local or general; but it 
cannot be doubted that in these the only peculiarity is, that the cause is 
hid from us. It should be remembered, as a fact of by no means very rare 
occurrence, that newly married women may cease to menstruate during 
several periods, as a result apparently of mere sexual excitement uncon- 
nected with impregnation. It is in the highest degree probable that these 
deviations from the normal standard, are due to unusual conditions of 
the ovary, which in one class of cases we may venture to assume as 
being unduly stimulated to attempts at ovulation, during a period at 
which that function should naturally be in abeyance ; while, in another 
class, its function is arrested by causes which may act upon the ovary, 
either specially through the generative apparatus, or constitutionally 
through the general system. 

The Digestive Organs are, during a pregnancy, the seat of various 
derangements of function, evidently depending on the sympathy which 
subsists between these upon the one hand, and the womb on the other. 
Although the exact period at which such symptoms develop themselves 
varies greatly, there is scarcely a single case of pregnancy in which, at 



148 PREGNANCr. 

some time or other, symptomatic digestive disorders do not manifest 
themselves. The most frequent of all is nausea, generally accompanied 
with vomiting, and this symptom, being of much more frequent occur- 
rence in the morning than at any other time of the day, has given rise 
to the name 7norning sickness. 

In the absence of any special cause which might give rise to nausea 
or vomiting, and if the general health apparently remains good, this 
sign is sometimes of considerable value. It is generally, however, to 
the early months that this nausea is limited, and it usually terminates 
or is mitigated about the time that the fundus may be observed above 
the pubes, having commenced probably about the fourth or fifth week. 
The period of development, and the duration of this symptom, are sub- 
ject to great irregularities ; in one case, it may be, beginning with the 
first days of pregnancy, and continuing to the last, while in others it 
does not commence until an advanced period, when local irritation of the 
stomach is more likely to be the cause. We have seen cases in which, 
at first, morning sickness was as marked as usual, to this succeeded a 
period of immunity, extending over several months, the nausea returning 
with great discomfort to the patient during the last weeks, being probably 
due in the first instance to sympathy, and in the latter to the efi"ect of 
proximity of the organs. Associated with the more familiar symptoms 
of morning sickness are others which also have their origin in the diges- 
tive system, such as heartburn, pyrosis, epigastric pain, and troublesome 
eructations. Repugnance to various articles of diet, which possibly Avere 
relished before pregnancy, or a longing for unusual, and even deleterious 
or disgusting substances, such as occurs in chlorosis, are by no means 
unusual symptoms. The symptoms manifested during one pregnancy are 
no sure criterion of their probable form in another ; for we often find 
that a woman, who has sufi"ered intensely in her first pregnancy from 
these digestive disorders, is on subsequent occasions remarkably free 
from them ; nay, it may happen that women, who have never had morn- 
ing sickness, complain of it for the first time on the occasion of a fifth or 
sixth pregnancy. All the affections alluded to constitute, when exces- 
sive, morbid conditions, and as such fall to be considered as disorders of 
pregnancy. 

Salivation, although not a symptom of any practical im.portance, is 
occasionally so marked in degree as to constitute a prominent feature in 
the case. In this, there seems to be a special glandular sympathy mani- 
festing itself in a hypersecretion, which may last during the whole term 
of pregnancy. 

Under the same category of phenomena which have their origin in 
the glandular system, we may here notice certain changes in the urine 
which, since the time of the ancients, have attracted attention as symp- 
tomatic of the pregnant state. About thirty years ago, a number of 
observers directed their attention to the investigation of this subject, 
but the person whose name is most intimately associated with it is M. 
Nauche, by whom the name hyeste'me was given to the substance re- 
ferred to. From the numerous observations which have been made, by 
him and others, it would appear that the period of pregnancy at which 
this has been discovered varies considerably ; that it is certainly not 



CHANGES IN MAMM^.. 149 

present in all cases of pregnancy ; and that it has been discovered in 
certain morbid conditions which have no relation to the pregnant state. 
This, of course, reduces the value of kyesteine as a sign of pregnancy to 
a low level ; but there can at the same time be no doubt whatever, that 
in a large proportion of cases the substance may be discovered. When 
the urine is fresh from the bladder, there is no appearance w^hatever 
which would enable us to distinguish it from the ordinary excretion. 
About the third day, or sooner, it commences to lose its transparency, 
and becomes hazy, as if mucus were suspended in it, and, shortly after- 
wards, distinct traces may be seen, on the surface, of the formation of a 
pellicle, which is at first thin and transparent, but subsequently becomes 
much thicker and more opaque. About the third or fourth day, the dis- 
tinctive characters of this pellicle usually reach their greatest intensity, 
and little flocculent portions then commence to detach themselves from 
its under surface, and sink through the liquid to the bottom of the 
vessel. The whole pellicle ultimately goes through this process, and 
becomes thus transformed into a whitish deposit which gravitates to the 
bottom, as did the flocculi first detached. The original pellicle is then 
replaced by another, which contains, as indeed may the first one, crystals 
of triple phosphate ; the liquid becomes more turbid, until, finally, the 
appearances characteristic of pregnancy become lost in the process of 
putrefaction. Kyesteine, then, first makes its appearance in the urine, 
under the form of a cloud, like cotton in suspension, which is due to the 
aggregation of little globules which exist in the urine when passed. 
These subsequently unite, rise to the surface, and constitute the pellicle 
which we have described. It is said that, when present in the urine, 
it persists from the end of the first month until delivery ; but the 
observations of Cazeaux throw much doubt on this assertion, as regards 
the last six weeks, for he tells us that he examined in 1849 the urine of 
fifteen women at this stage of pregnancy without discovering any trace 
of it. Chemical and microscopical researches seem to show that Kyesteine 
is a new formation, and is an azotized substance, and that it presents itself 
under the form of minute globules. As a sign of pregnancy it is of little 
or no value. 

Changes in the Mammce. — The raammse are, from an early period, the 
seat of certain symptoms and changes, which are justly looked upon as 
of great importance. When we reflect on what their proposed function 
is, we cannot marvel that, even thus early, they become the seat of 
changes, which are evidently designed with the view of elaborating, and 
otherwise preparing, these important structures against the time when 
they will be called upon to discharge the function in question. The 
earliest indications which are given by the mammge of the existence of 
pregnancy, are certain vague sensations, which are described by the 
w^oman as of fulness and weight, but which not unfrequently amount to 
considerable uneasiness, and even acute pain. This points to the awakened 
activity of the organs, further evidence of which is soon shown in a con- 
siderable increase of volume, due obviously to the greater afflux of blood, 
which dates from the earliest weeks, and which manifests itself at a more 
advanced period, by the presence of large blue veins, which may be seen 
coursing under the skin, more conspicuously in a woman of a blonde 



150 PREGNANCY. 

complexion. To the touch, the gland seems harder than usual, and here 
and there may often be felt clusters of enlarged milk vessels, which give 
the impression of knotting. Towards the end of pregnancy, or at a much 
earlier period, if the distension of the mammge is extreme, silvery white 
lines are seen upon the surface of the breast, radiating from the nipple 
as from a centre. These arise from distension of the cutaneous struc- 
tures, and yielding of the corium at some points, so as to give facility to 
the expansion due to growth of the gland. 

The secretion of milk in the breasts has very generally been supposed 
by the vulgar to be an infallible sign of pregnancy, either past or existing. 
Nothing can be more erroneous than such a conclusion ; but, at the same 
time, the presence of milk in the ducts is, when taken along with other 
signs, often of very considerable importance. It is proper to mention, 
however, that not only is milk in the breasts no certain sign of pregnancy, 
but numerous cases are recorded by Montgomery and others, where the 
breasts of young women who had never been pregnant, and of old women 
past child-bearing, have yielded milk in sufficient abundance to suckle a 
child. A striking case of this nature was narrated to the writer by Dr. 
Livingstone, the renowned African traveller, who had so investigated the 
circumstances as to eliminate even the possibility of doubt. A native 
w^oman was delivered of twins, and not being constitutionally very robust, 
was unable to nurse both, whereupon the grandmother, a woman of sixty, 
took one infant, when, after repeatedly placing it to the breast, the secre- 
tion was so abundantly established, that she proved an excellent nurse. 
Nay, more than this, there have been cases in which the gland in the 
male has secreted milk in considerable abundance. 

Surrounding the nipple, and circumscribed by a circle of about three- 
fourths of an inch radius from its centre, the skin presents, in the adult 
and unimpregnated condition, a peculiar appearance, which consists 
chiefly in an increased depth of color. It is thin and delicate, and pre- 
sents to the eye the semblance of a structure intermediate between skin 
and mucous membrane. From its surface, small glandular eminences, 
varying in number from twelve to twenty, or more, may be seen to pro- 
ject slightly. This area, which is called the Areola, is the seat during 
pregnancy of changes which are frequently of the greatest importance 
in strengthening the presumptive proof which may already exist ; but it 
must always be remembered that changes, closely resembling those which 
Ave are about to describe, may be produced by causes which have their 
seat in the generative system, but which are independent of pregnancy ; 
and, moreover, that as the changes are to a considerable extent permanent, 
it is in first pregnancies that they have the greatest diagnostic value. 
The following are the appearances referred to : If the breast be carefully 
examined about the ninth week, a considerable increase in the size of the 
nipple will almost always be observed, this structure having become turgid, 
and, as it were, erect. Simultaneously with this, or closely succeeding it, 
there is a deepening in the color of the areola, an increase in its diameter, 
and a greater prominence and development of the follicles which stud its 
surface. It participates, obviously, in the increased vascularity of the 
nipple, and becomes, like it, moist and turgid. The alteration in color, 
which is due to this turgescence, takes place in all cases ; but it is only 



PIGMENTARY DEPOSITS. 



151 



in women of dark complexion that the characteristic changes of the areola 
are to their fullest extent manifested. In these, there is an actual deposit 
of pigment, and the depth of the color is, towards the termination of the 
pregnancy, not unfrequently such as to present a most striking and pecu- 
liar appearance. Examination of the follicles has shown that they are 
possessed of excretory ducts, through which their secretion may, under 
certain circumstances, be expressed. 

At a period not earlier than the fifth month, there may generally be 
observed, in women in whom the areola is deep in color, some trace of 
what Montgomery has described under the name of secondary areola^ and 
to which he attaches great diagnostic significance, amounting, indeed, in 
his opinion, to a certainty of pregnancy independent of other signs. This 
secondary areola, which immediately surrounds the other, is, even when 
most distinct, very faint in color, and has been well compared to the effect 
produced by drops of water falling upon a tinted surface, and discharging 
the color. An attempt has been made in the accompanying cut (Fig. 
83), to indicate the various appearances referred to. 

Fig. 83. 





Areola and Secondary Areola in Seventh Month, of Pregnancy. 



The pigmentary deposit, on which the appearance of the areola of 
pregnancy in a great measure depends, is not in every case limited to 
the situation in question. In a large proportion of cases, a dark line, 
about a quarter of an inch in width, may be observed running along the 
middle line of the abdomen, from the symphysis to the umbilicus, and 
occasionally extending from thence as far as the ensiform cartilage. A 
dark colored disk, occupying and surrounding the umbilicus, was occa- 
sionally observed by Montgomery, and is described by him under the 



152 ' PREGNANCY. 

name of the " umbilical areola ;" and brownish streaks, analogous to the 
silvery lines in the breast, are not uncommonly to be seen in the abdomi- 
nal Avails, running parallel to each other, and generally curved, with the 
convexity towards the groins. These streaks lose their color, but do not 
disappear after delivery, and are therefore of some importance in deter- 
mining the question of previous pregnancy. As an occasional concomitant 
of pregnancy, there has also been observed a more general discoloration 
of the skin, so much so, indeed, as to give rise, in one case at least, to 
the suspicion of existing disease of the supra-renal capsules. In the case 
in question, the whole forehead, and part of the cheeks, neck, and breast, 
was deeply tinged of a yellowish-brown color ; but within a few weeks 
after the birth of the child this had completely disappeared, nor was 
there at any time the slightest symptom, in addition to the discoloration, 
to encourage the belief in the existence of the disease of Addison. In 
other instances, discoloration of the skin during pregnancy has been 
found to be due to the presence of 'pityriasis versicolor. 

The appearance of the abdomen, although a very conspicuous sign of 
pregnancy, can only be admitted as such on the careful exclusion of cer- 
tain sources of fallacy. For not only may solid tumors of various kinds 
give rise to appearances very similar, but fluid accumulations, such as 
ovarian cysts or dropsical effusions, or even distension of the bladder, 
may delude the unwary into a hurried and erroneous diagnosis. It be- 
hooves the observer, therefore, to be careful how he admits this point in 
evidence. Cessation of the menses, with abdominal enlargement, would 
almost certainly be admitted by an expectant mother and her friends as 
proof sufficient; but it sometimes falls to the duty of the medical at- 
tendant to dispel such illusions. Passing over, for the moment, the 
evidence to be derived in such cases by the practice of palpation, a 
certain amount of information may be obtained by the eye alone, in 
examining the abdomen in the various stages of pregnancy. 

As we have already seen, the uterus, during the early weeks of preg- 
nancy, instead of rising upwards, into the abdominal cavity, actually falls 
downwards towards the floor of the true pelvis. This fact gives rise to 
the earliest modification in the outline of the abdomen, which consists, 
not in an enlargement as might have been expected, but in a slight 
flattening of the hypogastric region. This fact has been long recognized, 
and, although its importance has been exaggerated, its expression is em- 
bodied in the old French proverb, quoted by all writers, " Ventre plat, 
enfant y a." Actual abdominal enlargement dates from about the thir- 
teenth or fourteenth week, but so much depends upon the figure of the 
woman, the number of children she has borne, the presentation of the 
child, and the quantity of liquor amnii, that the mere study of the 
abdominal outline would, in so far as uterine development is concerned, 
rarely afford us reliable information. Another observation which should 
be made, consists in a careful examination of the umbilicus. During the 
first three months, the depression of the navel is, if altered at all, some- 
what deeper than usual. On the expiry of this period, it regains its 
original appearance. In the course of the fourth month, it becomes less 
hollow than before conception, and, from this time, the depth of the 
cavity becomes gradually diminished until, about the seventh month, it 



EXTERNAL APPEARANCE OF ABDOMEN. 153 

becomes completely effaced, and is on a level with the surrounding skin. 
Nor do the chano;es of the umbilicus cease here, for during the last two 
months the umbilicus protrudes beyond the surface, being, as it were, 
inverted by the pressure which is brought to bear on the inner surface of 
the abdominal wall by the distending womb. This is a pretty constant 
sign, and is certainly the most important to be derived by an ocular ob- 
servation of the abdominal surface ; but similar phenomena may be 
caused by ascites and tumors. 

In so far as external appearance is concerned, there is scarcely any 
variety of solid tumor connected with subjacent organs, nor even any 
tumor due to fluid or gaseous distension, which may not, under certain 
circumstances, give rise to the suspicion of pregnancy. It is rarely, in 
practice, that the differential diagnosis of such aft'ections presents any 
great difficulty ; but there are cases in which difficulties undoubtedly 
exist, when recourse must be had to percussion and palpation, to remove 
such doubts as may arise. Such an examination enables us to determine 
the shape and limits of the tumor, and the relation which it bears to the 
bowels and other surrounding parts. Nothing is here of such importance 
as the consistency of the tumor. The extreme hardness of uterine 
fibroids, on the one hand, and the yielding softness of gaseous or fluid 
distension on the other, represent the extremes ; between which endless 
varieties exist. But the uterus, when distended, communicates to the 
hand a feeling so peculiarly its own, as to enable any one possessed of 
the requisite tactus eruditus to pronounce on the subject almost with 
certainty. This feeling consists in a certain elasticity which, although it 
may be simulated, is different from that which is communicated by any 
other form of abdominal tumor. Besides this, the practice of palpation 
often causes a certain amount of feeble, painless contraction in the womb, 
which, when distinctly felt, is of the highest diagnostic value ; but it 
must be remembered that these symptoms prove only that it is the uterus 
which we are touching, and are no evidence of pregnancy. If, however, 
we are convinced that the elastic tumor contains a solid movable body, 
there is scarcely any room for doubt. In cases where, from unusual 
thickness of the abdominal walls, or from some other cause, palpation 
gives obscure results, the history of the tumor, and, especially, the situa- 
tion in which it was first observed, are points which may have special 
value. If ovarian, the tumor may perhaps have been observed, in the 
first instance, in either groin ; if from the spleen or liver, the history will 
be of a growth developing from above downwards, instead of the globular 
uterine swelling, first observed in the middle line behind the symphysis, 
wdiich steadily increases in an upward direction, and the nature of wdiich 
is probably revealed by other important symptoms, some of which have 
already been detailed. In those cases, in which the tumor is proved to 
be the uterus — but the fact of pregnancy is still in doubt — there is always 
the possibility of the cavity being distended by other contents. Actual 
difficulty, even in experienced hands, and error in diagnosis, are most 
likely to occur in those cases in w^hich pregnancy coexists with some of 
the morbid affections above alluded to. We may have, for example, 
clear evidence of ovarian disease — a tumor, we shall suppose, partly 
cystic and partly solid, springing from either groin, and slowly increasing 



154 PREGNANCY. 

in size. In such an instance, on the occurrence of pregnancy, the abdo- 
minal tumor will increase with much greater rapidity ; but, one cause of 
abdominal enlargement having already been established, the possibility 
of a coexisting cause may quite slip out of notice, and thus very serious 
mistakes have, in some cases, actually been made. When we come to 
consider the diseases and complications of pregnancy, we shall find that 
there are many other morbid conditions, which, when associated with it, 
tend greatly to obscure the diagnosis. 

Vaginal Examination. — Important information, either positive or 
negative, is aiforded at all stages of pregnancy by vaginal examination. 
In the early months, the descent of the uterus causes an apparent short- 
ening of the vagina, and an increase in its width from side to side ; but, 
from the end of the third month till towards the end of gestation, — when, 
as we shall see, the womb again falls downwards, — the extension of the 
vagina upwards results in an elongation and a consequent proportional 
narrowing of its diameters. There is clear evidence here also of in- 
creased activity of the circulation, corresponding to that which we have 
found to exist in the internal genital organs. It takes the form, in this 
situation, of a venous engorgement, which is due, in part at least, to ob- 
struction, caused by pressure of the gravid womb, and is indicated by a 
more or less livid color of the mucous membrane— very different from the 
rose color of the unimpregnated state. This ocular examination of the 
parts, although it may thus reveal a sign which is far from being the 
least important, is, for obvious reasons, a method of research which can- 
not be generally adopted in the practice of midwifery, so that we have 
to depend here upon the results which are afforded by an examination 
conducted, under the bedclothes, by the finger. 

Under the head of digital examination, the first symptom which often 
comes under our observation is one which is due to the increased vascu- 
larity of the parts to which reference has just been made, and consists 
in strong pulsations, which are obviously due to enlargement of the 
vaginal arteries. This, which is a sign of no great importance, has been 
described by Osiander under the name of vaginal pulse. During the 
later months it is by no means unusual to find the mucous membrane 
hypertrophied and covered with small granulations or papillary projec- 
tions, which are supposed to be the result of an abnormal development 
of the mucous follicles, and which are, certainly, often accompanied by 
an augmented mucous secretion. The chief, and in many cases the 
sole, object of vaginal examination is to ascertain the condition and 
anatomical relations of the inferior segment of the uterus ; and, more 
especially, the state of the os, and of that portion of the cervix which 
projects into the vagina. In those early weeks, during which the uterus 
descends within the cavity of the true pelvis, the descent is accompanied 
by a certain amount of anteversion, which enables the experienced ac- 
coucheur, as early as the sixth week, to recognize in the anterior vaginal 
cul-de-sac a fulness or slight resistance, which is absent in the normal 
and unimpregnated condition of the parts. 



CHANGES IN THE CERVIX UTERI. 155 



CHAPTEE IX. 

SIGXS OF PEEGNANCY (Continued). 

Chanrjes in the Os and Cervix Uteri: Progressive Softening of: Characters of at 
Various Stages.— Position of Os in Relation to Pelvic Walls. — Digital Ex- 
amination or ''■Toucher.'' — Examination per Anum. — Quickening: Ecetal 
Movements Observed^ (a) hy the Mother, (h) ly the Accoucheur. — Ballotte- 
ment or Repercussion. — Foetal Pulsation. — Funic Souffle. — Uterine Souffle: 
Theories as to its Production. — Stethoscopic Examination of Foetal Movements. 
■ — Division into Certain and Probable Signs. — Tabular Resum6 of the Signs 
of Pregnancy. 

It is from the observation of the Os and Cervix Uteri that the most 
important information is derived in the course of a vaginal examination ; 
for not only does this give us indications of pregnancy at a very early 
stage, but it enables us in many instances to judge, approximately at 
least, of the stage which the pregnancy has attained. From a very 
early period of gestation a difference takes place in the firmness and 
resistance of the cervical tissue, which is due, in the first instance, to 
the congestion and hypertrophy of which this, as well as the other por- 
tions of the uterus, are, immediately after conception, the seat. But, in 
addition to this, there is a special change, which a few careful examina- 
tions by the finger will enable any one to recognize, and which is admi- 
rably described by Cazeaux. ^'Towards the end of the first month," he 
says, " one may already discover that, in addition to the first general 
modification, that portion of the lips of the os which is situated most 
inferiorly, or rather most superficially, begins to soften. This appears 
to be rather an oedematous condition of the mucous membrane, than an 
actual softening of the tissue proper of the lips, so that, in pressing 
slightly upon the thick and softened membrane, the finger at once per- 
ceives its fungous softness, but seems immediately afterwards to reach 
the tissue proper of the neck, which still retains its normal consistence. 
The sensation thus conveyed closely resembles that which we obtain if 
we press with the finger upon a table which is covered with a thick and 
soft cloth. It is not till towards the termination of the third month, or 
the beginning of the fourth, that the entire thickness of the lips of the os 
is softened, to the extent of two or three millimeters. From the fifth 
month, the softening extends from below upwards, and, at the sixth, 
reaches the centre of the vaginal portion of the cervix. During the 
three last months, it invades, step by step, the superior part, until it 
reaches the internal os, so that, at the end of pregnancy, the neck is so 
soft, in the case of certain women, that I have often observed that 
students had great difficulty in distinguishing it from the walls of the 
vagina." This, according to the distinguished accoucheur from whom 



156 PREGNANCY. 

we have quoted, is very constant in its occurrence, and should be looked 
upon as a very important sign of pregnancy, unless it be in cases where 
the tissue of the cervix is the sea.t of pathological alterations. 

The shape of the os and cervix also undergoes, during the advance of 
pregnancy, some very remarkable changes. The os very early loses the 
form of a transverse slit, and becomes more circular in form', while the 
comparative softness of the tissue admits sometimes of the introduction 
of the point of the finger. This becomes much easier as pregnancy ad- 
vances ; and the softening process described by Cazeaux extends, so 
that, by the sixth month, it is occasionally possible, even in primiparae, 
to introduce the point of the finger. A reference to the diagram already 
shown (page 144) indicates the manner in which, according to the ideas 
originally entertained by Desormeaux, the canal of the cervix is invaded, 
in the march of development, by a process of encroachment from above 
downwards, dating from the sixth month, or, according to some, even 
earlier. It requires, however, no very extensive study or observation of 
the facts to show that no such simple description will afibrd a satisfactory 
explanation of the facts as they come under observation in practice. A 
shortening, or apparent shortening, of the vaginal portion of the cervix 
is, more especially in primiparge, undoubted; but are we entitled to ac- 
cept this observation as conclusive, or even as carroborative, evidence of 
the views of Desormeaux ? No one, we should imagine, can hesitate, on 
reflection, to answer this query in the negative ; but yet we can scarcely 
doubt that this has been accepted by many as sufficient evidence of the 
doctrines to which they subscribe. 

This theory, although so convenient in its simplicity, is one which many 
writers, both of the past and the present century, have found it impossi- 
ble to adopt ; but, unfortunately, of the dissenters, no two seem to have 
reached precisely the same conclusions. In fact, this, so far from being 
a simple matter which admits of clear demonstration by a few strokes of 
the pencil, is at the present day a subject which still requires renewed 
and careful examination. In rejecting, as we may safely do, the theory 
of Desormeaux as applicable to all cases, it still remains for consideration 
whether it is applicable to any case whatever. 

In so far as primiparse are concerned, the views of Schultze seem to 
confirm those of Desormeaux, except that the latter believed the invasion 
of the cavity of the cervix to date from a still earlier period. In Figs. 
84, 85, and 86, the conditions indicating the primiparous os are clearly 
indicated ; but, as regards the period at which the resistance of the os in- 
ternum is first overcome, the researches of Stoltz, and the more recent 
observations of Matthews Duncan, not only throw doubt on the views 
formerly entertained, but go a long way to disprove them. Indeed, the 
belief is now steadily gaining ground that, even in primiparse, it is only 
during the last fortnight that the encroachment upon the canal of the 
cervix takes place, — Duncan, indeed, believing that its dilatation is only 
effected by the painless uterine contractions of the last few days of preg- 
nancy. 

Practical investigation of the matter is unfortunately beset with no 
little difficulty, for not only are the opportunities of post-mortem exami- 
nation few, but the circurmstances are such, in most cases, as to render 



CHANGES IN THE CERVIX UTERI. 



157 



Diagrams showing (according to Schultze and others) the Rela- 
tion WHICH the Canal of the Cervix bears to the Cavity of 
THE Uterus during Pregnancy. 




PLURIPAK-aE. 

Fiff. 87. 




Tweutv-fourtli Week. 



Fi^. 85. 





Thirtieth Week. 



Fie. 86. 



Fig. 89. 




At Full Term. 



crucial observations in the living subject impossible without the risk ot 
inducing premature labor. Our belief is that all cases do not follow the 
same law ; but we have had no difficulty in convincing ourselves that, 
even in the last days of pregnancy, when the feel of the os externum and 
the apparent proximity of the presenting part would seem to imply that 
the entire canal of the cervix was lost, there often exists a canal between 
the OS externum and a point considerably higher, which passes obliquely 



158 



PREGNANCY. 



through the uterine wall (Fig. 90). Stoltz and Cazeaux supposed that 
shortening of the canal of the cervix takes place without any yielding 
of the OS internum, — the os internum and the os externum being approxi- 
mated in consequence of the softening of the tissues above referred to. 
In other words, they supposed that the width of the cervix was increased 
at the expense of its length, and that, therefore, the shortening of the 
canal of the cervix in primiparse (Fig. 91) is apparent and not real. 



Fiff. 90. 



Fig. 91. 





Apparent Shortening of Cervical Canal. 

As regards the process in pluriparae (Figs. 87, 88, and 89) there is less 
difiference of opinion, and we find that the ideas entertained by Schultze, 
and represented in the diagram referred to, differ very little from those 
promulgated by Stoltz and Cazeaux, and corroborated by the more ex- 
treme views of Matthews Duncan. The softening process attacks the 
tissue of the cervix in a manner precisely similar to that which obtains in 
the case of primiparse. There is in this case, however, a gaping external 
orifice, which admits easily, even earlier than the twenty-fourth week, 
the point of the finger. From this period onwards, till about the thirty- 
sixth week, the only change which takes place is, that the cavity of the 
cervix becomes more and more accessible to the finger, which slips into 
it, as Cazeaux says, as into a thimble. The mechanical effect of previous 
pregnancy seems to be that the cavity proper admits of easy and ample 
distension, so that no call is made upon the cavity of the cervix until the 
termination of pregnancy approaches. Even in those instances in which 
the cavity of the cervix is most easily permeable by the examining finger, 
the OS internum is, in pluriparee, often found quite impassable at the thirty- 
seventh week, or even later. From this period, however, a very rapid 
shortening of the cervix takes place until, at the fortieth week, as in 
primiparse, the cervix is in a manner effaced. But there remains to the 
last, instead of the thin, smooth, and almost membranous margin of the 
OS in primiparae, an irregular oedematous lip which is in the highest de- 
gree characteristic, and which is not wholly lost even during the first stage 
of labor. There is represented in the diagrams (Figs. 87, 88, and 89), — 
which may be compared with the adjoining figures, — the distinguishing 
features of the pluriparous os, as observed from the vagina. 

Rapid as is the process by which the uterus is reduced in size after de- 



THE "TOUCHER." 159 

livery, it never completely regains its virgin state. The os and cervix 
are the parts which show most distinctly the peculiarities which attach to 
those who have already borne children ; and in the course of a digital 
examination, this peculiar feature comes prominently under our notice. 
This method of examination, therefore, enables us not only to recognize 
the stage of the pregnancy, but also to distinguish between first and sub- 
sequent pregnancies — due regard being had to the manner in w^hich the 
cervix is developed in the two classes of cases. 

The situation of the os uteri, relatively to the walls of the pelvis, is 
another point which is disclosed in the course of a vaginal examination. 
This is, however, of more importance in conveying information as to the 
stage of pregnancy than in regard to the fact of its existence ; but as it 
may, under certain circumstances, become an important point in evidence, 
its omission here would be improper. We have already seen that, in 
consec|uence of the growth downwards of the uterus, the os is, in the first 
instance, displaced in the same direction, and, as we believe, somewhat 
backwards, this movement corresponding to the slight anteflexion to which 
reference has already been made. The escape of the uterus from the 
true pelvis, and the subsequent and rapid upward development of its 
body, soon cause a corresponding movement upwards of the os, which 
thus seems to follow the fundus, in proportion to its development, steadily 
upwards in the pelvis from the tenth to the thirty-seventh week, when it 
attains the highest point, and is reached by the finger sometimes with a 
little difficulty. With the descent of the uterus in the last weeks, it 
again sinks downwards, and, at the same time, moves backwards ; so 
that, though lower, it is not more within reach of the finger. This final 
movement corresponds to the falling downwards and forwards of the 
fundus, mention of which has already been made. Sometimes the head 
descends to an unusual degree in the pelvis, and, in such cases, may push 
before it the anterior segment of the uterus. From this cause a diffi- 
culty occasionally arises, which may even give rise to the suspicion of 
atresia ; but a careful examination by the finger, in the direction of the 
hollow of the sacrum, will rarely fail to disclose the position of the os — 
the difficulty being, of course, greater in first than in subsequent preg- 
nancies, owing to the membranous thinness which the lips of the womb 
frequently, in these cases, assume. 

In the practice of the toucher^ or digital examination of the vagina, 
skill and experience are of paramount importance ; and, as it is by 
practice alone that the required dexterity can be attained, it behooves 
the student to avail himself of every opportunity which may arise for 
adding to his store of experience. With this view, some uniform 
scheme or method of examination should be adopted. A long finger is 
doubtless an advantage, but the advantage is by some writers greatly 
exaggerated. The index finger may alone be used, but some prefer 
to use two, by which we no doubt gain something from the greater 
length of the second finger. This advantage, however, is frequently 
counterbalanced by the increased pain which the examination gives the 
woman, causing her to shrink and draw away from the hand of the 
accoucheur. The finger should be passed forward from the situation 
of the coccyx over the anus and the posterior commissure of the vagina. 



160 PREGNANCY. 

It may seem almost too ridiculous to suppose that the anus should in 
such an examination be mistaken for the vagina, but the knowledge of 
the fact that the mistake has been committed will suffice to prevent the 
student from a similar error. The finger should be well oiled or smeared 
with lard, with the object, in all cases, of facilitating introduction, and, 
in a certain class of cases, to protect the finger. Notice is to be taken, 
as a matter of routine, of the state of the perineum, labia, and other 
parts. The condition of the vagina and rectum, and of the pelvic walls, 
must, in like manner, not be overlooked, for, in all questions bearing 
upon pregnancy, the state of these parts must have a special interest, 
and the timely recognition of anything abnormal may have the effect of 
averting a calamitous result. In the actual examination of the os and 
cervix, some assistance will occasionally be derived from the use of the 
hand over the surface of the abdomen, by which the fundus may be 
steadied and the os pressed downwards more within the reach of the 
fino;er. In conductins; such investio;ations as Ave have been referrino; to, 
the strictest caution must in every instance be exercised in order to 
obviate the possibility, which exists in every case, of premature labor 
being induced by rude and careless hands. The amount of irritation 
necessary to excite the uterus to contraction varies greatly in different 
cases, but we cannot doubt that incautious interference, more especially 
with the OS and cervix, may incite contraction, and cause the loss of the 
product of conception. 

In the investigation of uterine diseases unconnected with pregnancy, 
it is often proper to institute an examination per anum. In the practice 
of midwifery, and the diagnosis of pregnancy, such a mode of examina- 
tion is very seldom necessary. Cases, however, do now and again occur, 
in which, owing, it may be, to excessive tenderness of the parts, or to 
partial obliteration of the vagina, the result of sloughing, we may be 
obliged to have recourse to this expedient. Or, again, it may be neces- 
sary for the proper examination of tumors, which exist as complications 
of pregnancy, and which are connected with the posterior part of the 
pelvis. And, in one other group of cases, we are recommended by 
Montgomery to examine thus, " when, for any particular reason, it is 
thought desirable to ascertain whether the uterus is enlarged within the 
first two months of supposed pregnancy." Under any circumstances, 
however, this mode of examination is so repulsive to the woman that, 
with that consideration for her feelings which should always sway us, 
we instinctively shrink from proposing it, unless the circumstances be 
such as to render it absolutely essential. 

Quickening. — The period of Quickening is that at which the mother 
becomes for the first time conscious of the movements of the foetus within 
her womb. They who at one time believed that the ascent of the uterus 
from the pelvis to the abdominal cavity took place suddenly, and was not 
a simple process of gradual evolution, held, naturally enough, the view 
that the quickening was this assumed sudden motion. Every woman now 
knows that it is due to the actual movements of the living child, which 
are at this period first communicated to her senses. The sensation, how- 
ever, does not represent the first movements of the child, for they are 
seldom perceived by the mother earlier than the sixteenth week, whereas, 



QUICKENING. 161 

in abortions at a much earlier period, vigorous movements are often ob- 
served after the expulsion of the embryo. Nor is it an uncommon thing, 
in the course of an abdominal examination by the hands and the stetho- 
scope, to feel or to hear slight movements which we can only suppose to 
be exercised by the foetus, and that too at a time when the mother may 
still be in doubt as to the fact of her pregnancy.^ The time usually 
stated as that of quickening is about the middle of pregnancy, or four 
and a half calendar months. This belief, although only a popular one, 
is sufficiently wide of the truth to call for correction, seeing that, in most 
cases, about the seventeenth w^eek may be assumed as the period at which 
women feel the first feeble flutterings which to them indicate the vitality 
of their offspring. In some instances, the movement is more decided, 
even at this time, but the rule is that it is at first very faint, and gradu- 
ally becomes stronger in proportion as the development of the foetus 
progresses. In the latter months, the foetal movements become so vigor- 
ous, that they may cause the woman actual pain, and have been known 
to cause her to cry out ; and, at this stage of pregnancy, the movements 
which are perceived are due to brisk flexion and extension of the joints 
of the lower limbs, the sensation being in some instances due to smart 
kicks, and in others to a continuous movement, such as might be caused 
by the passage of the knee along the inner uterine wall. Important as 
this sign is to the accoucheur, and all important as it is to the woman, it 
is nevertheless one in regard to which we must always be cautious, as 
there are fallacies wdiich may lead astray even those women who have 
previously borne children, and who may thus be supposed to be familiar 
with the sensation m question. The conditions which may give rise to 
such erroneous impressions are rapid movements of gas in the intestines, 
irregular contraction of the muscles of the bowels, or even of the muscles 
which form part of the abdominal walls ; and the pulsatile movements of 
an aneurism, or of a large artery, which, being communicated to a tumor 
w^ithin the abdomen, may very readily deceive a woman who already 
suspects that she is pregnant. Such cases are so frequent, that we must 
always be careful in receiving as evidence the mere statement of the 
woman. 

We have hitherto spoken only of the active movements of the foetus, 
as observed by the mother. But these movements receive, as evidence 
of pregnancy, a vastly increased significance, if, in addition, the accou- 
cheur is able to convince himself of their reality, which he generally can 
succeed in doing by careful abdominal palpation. The nature of the 
tumor, its symmetry, and its elasticity, will already have prepared him 
for the corroborative evidence which he expects, and a very ordinary skill 
will prevent him from being misled by any disturbing influences, such as 

1 It is now generally believed that the mother cannot be conscious of the foetal 
movements until the uterus comes in contact with the abdominal walls. It is then 
for the first time possible that the sensation can be transmitted by sensory fibres of 
the cerebro-spinal system ramifying in the abdominal parietes. This theory ac- 
counts, as it appears to us, quite satisfactorily, for the phenomena which exist ; for 
we cannot doubt that the limbs of the child must strike the uterine walls at an 
earlier period than they are perceived by the mother, and it is not to be expected 
that the sensation could be communicated through the few filaments which reach the 
uterus from the cerebro-spinal system, as these are confined to the os and cervix. 
11 



162 PREGNANCY. 

may deceive the woman. He is conscious of the presence under his hand 
of a solid body, contained within an elastic tumor. He presses this body 
from side to side, and in various other directions, with the almost certain 
effect, if the child be alive, of causing such movements as, from the fifth 
month onwards, will place the question of pregnancy beyond the possi- 
bility of doubt. His eye, meanwhile, may follow many of the more 
violent of these movements, the abdominal wall forming from time to time 
distinct projections, corresponding to the subjacent portion of the limb or 
body of the foetus, so that the outline of the abdomen is for the moment 
distorted, the projecting part often suddenly changing its site before it 
sinks down again within the liquor amnii. But even here we are not safe 
from error, as, in some instances, movements closely resembling those of 
pregnancy have been observed by the accoucheur. The only condition, 
however, which might mislead any one using ordinary care, is that which 
arises from spasmodic action of the abdominal muscles. 

An interesting example . of this occurred several years ago in the 
Glasgow Royal Infirmary, in one of the wards at that time under the 
care of the writer. This woman was thirty-two years of age. She had 
been married for several years, but had had no children. She had been 
admitted on account of bronchitis, and was highly hysterical. She stated 
that she was pregnant, an assertion which at first attracted little attention, 
but as she stated subsequently that she had been pregnant for fourteen 
months, the case was looked upon with some interest by the gentlemen 
attending the clinique. The symptom upon which she founded her belief 
was the motion of the child, which she said she felt frequently and quite 
strongly. On examination, a tumor was observed in the abdomen, some- 
w^hat to the left of the middle line, reaching as high as the umbiRcus, 
and not at all unlike the gravid uterus at the sixth month. When the 
hand was placed over this and held steadily for a little, distinct jerking 
movements were noticed, which, for the moment, seemed to have some 
resemblance to such as might be caused by a foetus in utero. A little 
further examination soon showed the true nature of the case: the tumor 
was tympanitic on percussion, and nothing like the outline of the uterus 
could be felt; the os, on vaginal examination, was found to have none 
of the characteristics of pregnancy ; the stethoscope gave a negative 
result. And to make things certain, the woman was put under the in- 
fluence of chloroform, when the tumor completely disappeared, and the 
suspicious movements ceased. The case was one of "phantom tumor," 
with spasmodic contraction of the abdominal muscles ; but no amount of 
reasoning could shake the patient's belief in her pregnancy, and she left 
the hospital in the full conviction that she was sixteen months gone with 
child, and that in the course of the succeeding month she would give 
birth to a child in an unprecedented condition as to development. 

Ballottement. — An important sign of pregnancy is also to be found, 
under certain special conditions, in the passive movements which may be 
imparted to the foetus. This sign has been called by some English 
writers " Repercussion," but is more familiarly known under the French 
designation "Ballottement," which is certainly the more appropriate of 
the two. The following is the manner in which this test is usually 
applied : The woman is placed in a position which is intermediate be- 



BALLOTTEMENT. 163 

tween reclining and standing, and a very convenient plan is to have her 
shoulders supported behind, while she sits on the edge of the bed, with 
her feet upon the ground. The fundus uteri is then steadied by one 
hand, while the index finger of the other is introduced in the usual way 
-into the vagina, with the palmar surface upwards. The finger thus 
placed is then brought into contact with the anterior segment of the 
uterus, near the cervix, where the presenting head of the child will gene- 
rally be most easily felt. A smart jerk is given upwards, and the finger 
then kept perfectly steady, in its original situation, when, if the attempt 
be successful, it will be found that the foetus, which had risen up in the 
liquor amnii, in obedience to the impetus which had been given to it, 
falls, in a few seconds, back into its original place, and seems to poise 
itself upon the tip of the finger, communicating to it the peculiar sensa- 
tion from which the test derives its name. 

Although the posture above indicated is that in which the sign of bal- 
lottement is most readily recognized, it is by no means the only position 
in which it may be made out. A precisely similar sensation, indeed, is 
communicated when the woman lies upon her back, or even (although 
more rarely) when she occupies the ordinary obstetrical position on the 
left side. The same effect may also be produced in the course of ab- 
dominal palpation, about the fifth or sixth month, when, if the woman is 
placed upon her side, in the horizontal position, and one hand passed 
beneath tlie projection, there will be felt, if the abdominal walls are not 
too thick, some portion of the body of the foetus resting upon the hand. 
This, not unfrequently, may be displaced, and will return upon the fin- 
gers precisely in the same manner, and on the same principle, as when 
the examination is conducted in the usual way.^ 

The sign of ballottement establishes the presence, in a fluid medium, 
of a solid body. This body must obviously be, on the one hand, of suffi- 
cient size to be perceptible to the sense of touch, and, on the other, of a 
size considerably less than the cavity which contains it. It is clear that, 
unless these conditions are fulfilled, the sign is not available for the pur- 
poses of diagnosis. Of this proposition it is an obvious corollary, that it 
is only during a certain period of a pregnancy that ballottement can be 
distinguished. Before the fourth month, the size of the embryo is so 
small that it is impossible to produce the movement ; but from this epoch 
till about the seventh month, it becomes more and more distinct. For a 
few weeks after this it may still be observed, although with greater diffi- 
culty ; but, during the last six weeks, this method of examination gives 
no result whatever, in consequence of the great size of the child, and the 
extent to which the uterine cavity is filled by it. For a similar reason, 
it is not available in twin pregnancy. The only exceptions to this rule 
are cases in which the quantity of liquor amnii is greater than usual. 
Ballottement, in the hands of an experienced practitioner, may be looked 
upon as a certain proof of pregnancy ; but by the inexperienced it is 
never to be relied upon, without strong corroborative evidence of some 

I Considerable attention has been given of late years, more particularly on the 
Continent, to the importance of abdominal palpation in the diagnosis of pregnancy ; 
and there is no doubt that in this way, under favorable circumstances, the presenta- 
tion, and even the position of the child may, with tolerable accuracy, be ascertained. 



164 PREGNANCY. 

kind. The conditions requisite for its production are all fulfilled, it 
must be remembered, in the case of calculus in the bladder, when the 
solid body may be displaced with ease in its fluid medium. Anteversion 
of the womb, too, has, on a hurried examination, given rise to sensations 
closely resembling those of ballotteraent. In admitting, therefore, that 
ballottement is a certain sign of pregnancy, we do so, we repeat, 
with the reservation that it is so in experienced hands alone. It is 
of special value when, the child being dead, the more certain signs are 
absent. 

Foetal Pulsation. — By far the most important of all the signs of preg- 
nancy, is that which is associated with the name of Mayor of Geneva, 
who was the first to discover that the heart of the foetus could be heard 
beating through the abdominal and uterine walls. This discovery was 
announced in 1818, but attracted little notice until several years later. 
The period at which these sounds become audible in the course of preg- 
nancy, is subject to considerable variation. It is certain that, as a 
general rule, it is not till the fifth month that they can be detected; but 
many trustworthy observers have asserted that they have heard them in 
the course of the fourth month, and even as early, in some few cases, as 
the eleventh week. This latter statement is generally looked upon with 
incredulity ; but there can be no doubt but that occasionally the sounds 
may be heard in the fourth, third, second, or even in the first week of 
the fourth month. On an averao;e of a laro-e number of cases, the 
eighteenth week may be stated as about the period at which we may 
expect to hear them. 

The cardiac pulsations are much more rapid than those of the mother, 
and are, like them, double, although indistinctly so. They, of course, 
lack the volume of the maternal sounds, and are further enfeebled by the 
distance from the ear, and by the nature of the intervening media. The 
frequency of the beats is increased by the foetal movements, and may 
thus be found to vary at different times ; but it generally ranges from 
130 to 160 in a minute. Some interesting observations made by Stein- 
bach and FrankenLauser seem to show that the heart's action is more 
rapid in females, by about fourteen beats in the minute, on an average 
of the two sets of observations. The pulse of the mother has no marked 
influence upon that of the child. It is scarcely possible, therefore, for 
any one who takes note of this frequency in the beats, to mistake them 
for maternal pulsations, which might, of course, under various anatomical 
and pathological conditions, be produced in any tumor under examination. 
The only case in which the possibility of difficulty can be admitted is 
where the maternal pulse is unduly accelerated by the existence of fever, 
or by some more transient cause ; so that, in practice, it is well to adopt 
the simple precaution of placing the finger upon the mother's wrist at the 
moment we are making the stetlioscopic examination, when, if there is 
obvious dichronism, we are sure of our diagnosis; while, on the contrary, 
if there is an approach to synchronism in the two pulses, caution is 
clearly indicated. 

The pulsation of the foetal heart is never heard over the whole surface 
of the abdomen, but, on the contrary, over an area which is always 
limited. This site varies with the presentation and position of the child, 



FCETAL PULSATION. 165 

and it is often only after prolonged exploration that a point is discovered 
where the sounds are clearly audible ; and, as we hav^e already shown 
that the presentation of the child is more constant the nearer it is to the 
end of pregnancy, it follows that the earlier the period at which the 
examination is conducted, the greater will be the variety in the site at 
which auscultation has a successful result. It is usual, with a view of 
saving time and trouble, to adopt a uniform plan in conducting this inves- 
tigation, beginning always at the point at which the sound, for well 
known reasons, is most frequently to be distinguished. The child lies, 
in the last months of pregnancy, in a large majority of cases, with the 
head downwards, and the back forwards and to the left, some portion of 
the back part of the trunk being thus brought into contact, almost inva- 
riably, with the uterine wall, somewhat to the left of the middle line. If 
we place the stethoscope over any portion of the uterus other than this, 
the layer of amnionic fluid which lies between our ear and the heart of 
the foetus cuts oif all acoustic communication ; whereas, at the point just 
named, there is continuity of solid tissue, and through that the sound is 
conducted. The extent of the area over which the sounds are heard de- 
pends, in a great measure, on the quantity of the liquor amnii, being 
greatest when it is scanty, while, with much liquid, a small portion only 
of the foetal trunk comes into contact with the uterine wall, and the area 
is thus proportionally small. The point, therefore, at which we have 
the best chance of at once catching the sound, is about midway between 
the umbilicus and the symphysis pubis, and somewhat to the left side. 
If the child is in what will be described afterwards as the second cranial 
position, the back being thus forwards and to the right, we may expect to 
hear the sound at a corresponding point to the right of the middle line. 
In the ordinary breech presentation the sound is heard as high as the 
level of the umbilicus, or even a little higher. In dorso posterior posi- 
tions, whether of the head or of the breech, the convexity of the spinal 
column being turned backwards sometimes constitutes a difficulty in 
auscultation, as is also created by an unusual quantity of the liquor 
amnii (Dropsy of the amnion), and b}^ various abnormal presentations of 
the child. If, however, an examination conducted with due care at any 
time after the fifth month, and in the course of which the whole of the 
abdominal surface has been carefully explored, fails to detect the foetal 
pulse, this, of itself, is very strong evidence, either that pregnancy does 
not exist, or, if it has existed, that the foetus is dead. 

It is generally believed to be possible to determine, by means of 
stethoscopic examination, the existence of a twin pregnancy by the 
following peculiarities : that, in twin pregnancies, the two hearts are 
heard beating at opposite points of the abdomen, and that they are 
frequently not synchronous in their action. If the latter point can be 
conclusively established by the simultaneous examination of two ob- 
servers, the case is clear ; but, in regard to the mere existence of pul- 
sation at two opposite points of the abdomen, this cannot be admitted as 
satisfactory proof. It has, by some, been asserted that the distinction 
is easy, and that, when we have pulsation at two points, in a single 
pregnancy, the sounds reach their greatest intensity midway between 
the two ; whereas, in a twin pregnancy, examination in the intermediate 



166 PKEGNANCY. 

area gives a negative result. This, if true, would be a sure and easy 
test ; but we are perfectly certain it is not to be relied upon, although 
it may represent the general rule. Still, taken along with the shape of 
the alDdomen, and the results of careful palpation, pulsation at two points 
is an important symptom in the diagnosis of twins, which are generally 
placed to the right and left in the womb. 

Funic Souffle. — Dr. E. Kennedy has described another stethoscopic 
sound, A\'hich is synchronous with the foetal heart. " In some cases," 
says he, " where the uterus and the parietes of the abdomen were 
extremely thin, I have been able to distinguish the funis to the touch 
externally, and felt it rolling distinctly under my finger, and then, on 
applying the stethoscope, its pulsations have been discoverable, remark- 
ably strong; and, on making pressure with the finger for a moment on 
that part of the funis which passed towards the umbilicus of the child, I 
have been able to render the pulsations less and less distinct, and even, 
on making the pressure sufficiently strong, to stop it altogether." This 
assertion of Dr. Kennedy's has been vigorously controverted in Germany ; 
but, even admitting the description to be absolutely correct, the observa- 
tion is one, as has been well observed by Dr. Tyler Smith, ^' which can 
hardly be of practical use, because, when the abdominal and uterine 
walls are so thin as to permit us to feel the pulsation of the funis through 
them, the other auscultatory signs of pregnancy, and the evidence ob- 
tained by palpation, must already have set the question at rest ; and, 
except under such circumstances, it must be very difficult to discover the 
funicular souffle." 

Uterine Souffle. — The " bruit de souffle," '' placental souffle," and 
" Uterine souffle" are among the most familiar of the designations 
which have been applied to another and an important auscultatory sign, 
which was originally discovered, in 1823, by M. de Kergaradec, but for 
whom, also, the more important observation of M. Mayor would have 
been overlooked. The various names by which the souffle is described 
point pretty clearly to the well-known fact, that speculations as to its 
nature and its cause have given rise to various theories, which display 
the existence of very contradictory opinions. All agree that the sound 
is maternal, not foetal, as its rhythm corresponds to that of the maternal 
heart. The universal acceptation of the term " souffle" shows that, in 
regard to the nature of the sound, observers are at one. But, in so far 
as its seat and mode of production are concerned, great divergence of 
opinion has existed. 

The Uterine Souffle, as, for reasons to be stated presently, and follow- 
ing Dubois, we prefer to call it, is distinguishable at an earlier period 
than the foetal pulsation. Dr. Kennedy, Avho has given much attention 
to this, as to the other signs of pregnancy, maintains that he has heard 
it as early as the tenth week ; but usually it is not till the sixteenth 
week, or even later — or, in other words, until the uterus is accessible 
to the stethoscope — that it can be made out. These remarks apply to 
examination through the abdominal walls ; for, if the metroscope of M. 
Nauche be used, it is possible that it may be heard at a somewhat 
earlier period. An occasional characteristic of the sound is that it is 
not constant. It may be distinctly audible at one moment, and may 



UTERINE SOUFFLE. 16T 

disappear the next, to return again in a short time — these changes 
taking place without any appreciable cause. In some cases, it is heard 
over the whole abdomen ; w^iile, in others, it is confined within a hmited 
boundary, usually in the region of the groins. Generally it is heard, in 
advanced pregnancy, over the whole of the lower part of the uterus, but 
not over the fundus, nor in the lumbar region ; but, in the earlier months, 
it may be heard over the symphysis, or wherever the uterus is accessible 
to the stethoscope. In regard to tone and pitch, the varieties are end- 
less — presenting, in fact, from the soft whiff to the musical cooing or 
rasping sound, all the peculiarities of aneurismal or cardiac murmurs ; 
and, what is not a little remarkable, it varies in this respect, not only in 
different individuals, but in the same individual at different times. 

If the observation be made during a labor-pain, a very striking effect 
is often found to be produced by the contraction of the uterine fibres, the 
sound becoming, in the first instance, louder, more sibilant, or even musi- 
cal, and then, at the height of the pain, becoming lost — to return, as it 
passes off, in the inverted order of the tones, as the pressure on the ves- 
sels is relaxed. It seems to have no fixed relation to the site of the pla- 
centa, and it certainly gives no reliable evidence, as might, perhaps, have 
been expected, as to where the placenta is situated in the uterus. The 
uterine souffle as a sign of pregnancy is, no doubt, valuable, and is to be 
distinguished from any other arterial sound by the absence of impulse, 
and its persistence in every posture ; but it must, on no account, be ad- 
mitted as a certain sign. For the attention which has of late years been 
given to the diagnosis of ovarian tumors has shown that one of the more 
constant signs of a pathological uterine tumor, and which goes far to dis- 
tinguish it from a similar structure which has sprung from the ovary, is 
the existence of a souffle, which has the closest possible resemblance to 
the souffle of the pregnant womb.^ Under no circumstances is the 
uterine souffle to be held as proof of the life of the child. 

A certain number of observers were long of opinion that the sound 
•which we are now considering was caused by pressure on the great arte- 
rial trunks which lie in the posterior part of the pelvis. This must at 
once be admitted as a possible cause of such a sound, seeing that pressure 
on arterial trunks of sufficient calibre may, in any situation, produce a 
souffle. But that this is not the case in pregnancy, seems to be proved 
by the fact, that such a change of posture (the prone position, for exam- 
ple), as would remove the uterus for the time being from the neighbor- 
hood of the vessels, never has the slightest effect in arresting the souffle. 
The view which was entertained by M. Kergaradec himself in regard to 
the production of the sound, was that it is produced in the utero-placental 
vessels, and on this account he named it the " bruit placentaire." That it 
is not so, is noAV universally admitted, and the idea was, indeed, completely 
refuted by the discovery that the sound is heard at so many various sites, 
and still more conclusively by the observations which have been made after 
delivery, and which have proved that not only may the sound be heard 
after the birth of the child, but even after the placenta has been expelled. 

I Many believe tliis to be due merely to pressure on neighboring large vessels. 
Sometimes it is so; but we are persa^ded that the cause of the sound is generally in 
the uterine walls. 



168 PREGNANCY. 

The theory which owes its origin to Dubois is as follows. This dis- 
tinguished accoucheur assumed that the blood, in passing from the uterine 
arteries to the uterine veins or sinuses, presented characters precisely 
analogous to those which constitute aneurismal varix, or which produce 
the souffle in erectile tissues. In all of these cases, as he observes, w^e 
have arterial branches discharging their blood directly into veins, the 
more rapid current joining a more sluggish one ; and this, he adds, " is 
undoubtedly the cause of the murmur and the bruit de souffle which is 
so remarkable in aneurismal varix and erectile tissues." His conclusion 
is that, very probably, the same causes within the uterine walls produce 
the same results. A theory somewhat similar to that of Dubois has been 
advanced by Corrigan, with the additional suggestion that the sounds are 
modified by pressure of the foetus against the uterine walls. De la Harpe 
believed that the sound was due simply to the multiplicity of currents of 
blood within the uterine walls : the sound from each vessel being, by itself, 
inaudible, but the aggregation of many giving rise to the familiar sound. 
Finally, there is the view of Scanzoni, who holds that the blood during 
pregnancy is in a chlorotic state, and that the sound is due mainly to 
causes which have their seat in the composition of the blood, and are ac- 
companied by murmurs analogous to those with Avhich we are familiar in 
the case of chlorotic women. The ingenious theory of Dubois may, no 
doubt, in some particulars, be inaccurate ; but the opinion now generally 
entertained of the cause of the bruit is — that it has its origin in the ute- 
rine walls, and neither in the vessels external to them, nor in the placenta 
within them, and that, therefore, the views of Dubois and Corrigan are, 
in all probability, very near the truth. 

As has already been observed, the movements of the foetus may occa- 
sionally be observed, by means of the stethoscope, at a very early period. 
This mode of investigation, which we owe to the younger Naegele,is one 
which is surrounded by so many difficulties and sources of fallacy that, 
important as it seems to be, it is never likely to be of any great practical 
worth. The possibility, however, which is undoubted, of thus recognizing 
foetal movements at a time when the other evidence must be very incon- 
clusive, is a point not to be lost sight of. Possibly this, as,well as the 
other stethoscopic sounds, might be early recognized by the use of the 
Metroscope, a modification of the stethoscope, which was devised by 
Nauche with the view of directly auscultating the uterus from the vagina, 
but which has fallen into disuse. 

The Signs of Pregnancy consist, then, of a few which are Certain, and 
of a considerable number which are Probable or Presumptive. The cer- 
tain signs are — 

1. The Sounds produced by the Pulsations of the Foetal Heart. 

2. The Active Movements of the child, distinctly felt by a skilled 
person. 

3. The Passive Movements, in which consists the sign of Ballottement. 
If any one of these signs is made out, the woman is incontestably 

pregnant. But, in regard to the negative evidence which is afforded by 
their absence, this can only be admitted as proof that the woman is not 
pregnant when the other signs are wanting; the absence of one is only 



CERTAIN SIGNS. 169 

sufficient to warrant a doubt. To the three certain signs above given, we 
might, perhaps, add a fourth — -the secondary areola of Montgomery; 
but, as this is open to doubt, and is only to be observed in a limited 
number of cases, we include it among the probable signs. 

It is quite unnecessary that the latter should be again enumerated. 
Singly they are of no value ; but, when a considerable number of them 
are simultaneously observed, in cases where pregnancy is expected, as in 
married Avomen, the evidence thus afforded is tacitly admitted as complete. 
For such a diagnosis, the medical attendant should not be held responsible ; 
but if it turns out, after all, to be a mistake, he will find that, in account- 
ing for the blunder, a large share of the blame will lie at his door. For 
a certain opinion, such as one would be warranted in giving upon oath in 
a Court of Justice, no combination of merely probable signs will suffice. 
In addition to these, however imposing their array, we must, in every 
case, have one at least of the certain signs, before we can, with all con- 
fidence, assert that a woman is pregnant. 

If the child is dead, it is obvious that two out of the three signs are 
no lono;er available ; but, in these cases, there may still be ballottement, 
or there may be present signs which are held to indicate the death of the 
foetus, and which will be noticed in their proper place. The questions 
may be put to us : Is pregnancy probable in this case ? or, Can you say 
with perfect confidence that the woman is not pregnant ? The reply to 
such questions must be given with the greatest caution, and Avill depend 
very much on the correct appreciation of the various probable signs, and 
the exact value which attaches to each, or to each group of such signs. 
In most cases of doubt, some period will be given as the probable or 
possible time from which, if existing, the pregnancy must date ; and it 
will be upon a careful analysis of the signs proper to such period of 
pregnancy as may thus be indicated, that our opinion will, in the end, be 
formed. With a view of facilitating such an investigation, the following 
table has been drawn up, in which is given the average period at which 
the various signs are available. 



170 



PREGNANCY 



o 
o 

ft 

O 
t-i 

<1 

>^ 
o 

pR 
o 

w 

o 
g 

o 



f3 



0) 

It 


Turgescence and increased tem- 
perature of external genitals, and 
of Vagina, the mucous membrane 
of which becomes darker. 


4 

-1-3 
a 

o 

m 

D 


Projections of foetus may be felt. 

Active movements may be ex- 
perienced by mother about the 
17th week, and felt by the ac- 
coucheur some weeks later. 

Pulsation of foetal heart about 
18th week. 

If the head presents, Ballotte- 
ment can be made out about the 
18th week. 

Dark lines on abdomen ; and 
secondary areola may also be ob- 
served. 


> p, 

o % 


Investing mucous membrane 
becomes thick and softened. 

Os in Primiparse becomes round; 
in Pluriparse it is more open, and 
admits the point of the finger. 


Softening extends gradually 
from mucous membrane to tissue 
surrounding os. 

Orifice closed in Primiparse ; 
in Pluriparae still more open. 


Softening further invades the 
cervix. 

In Primiparse, os circular, 
smooth, and closed. In Pluri- 
parse, irregular, nodulated, and 
usually admitting, without diffi- 
culty, the point of the finger. 


S 
.2 

1 _ 

k 

.2 

o 


Volume and weight increased : 

Lower in pelvis : 

Os displaced downwards. 

Very slight hypogastric flatten-, 
ing and depression of Umbilicus. 

Fundus still below the level of 
the pelvic brim. 


Fundus passes brim about 12th 
week, and is midway between 
pubes and umbilicus at end of 
16th. It is distinguished by pal- 
pation and percussion. 

Less depression of Umbilicus ; 
hypogastric flattening disappears. 

Os reached with more difficulty, 
and is situated somewhat to the 
left. 


Fundus gradually rises ; is a 
little beneath the umbilicus at 
the 20th, and a little above it at 
the 24th week. 

Rounded central tumor in hypo- 
gaster becoming gradually more 
apparent. 

Umbilical depression almost ef- 
faced. 

Os and cervix still higher. 


o 

-2 

'w ■ - 

5 a 




Suppression of Menses (occa- 
sional exceptions). 

Swelling and pain in Breasts. 

Morning sickness, and other 
digestive derangements. 


Marked enlargement of Breasts, 
with prominence of nipple, and 
slight deepening color of the 
Areola. 


Areola becomes distinct, the 
Follicles projecting beyond the 
level of the skin. 

Morning sickness, and other 
digestive disturbances less. 

Certain effects of mechanical 
compression now often observed, 
such as varicose veins, and oedema 
of the genitals. 


•S2198AV 


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•qj9X oj qj6 


•qj^^ oj qjix 



TABULAR RESUME. 



171 



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172 DURATION OF PREGNANCY. 



CHAPTEE X. 

DURATION OF PREGNANCY— SUPERFCETATION. 

Duration OF Pregnancy: in Coios and Mares: in Women. — Protracted Preg- 
nancy : Cases of. — Difference in Rate of Development. — Mode of calculating 
the probable Time of Delivery: Calculation from last Menstruation to be 
corrected by Period of Quickening. — Superfcetation : to be distinguished 
from Super fecundation. — Proofs of the latter. — Twin Pregnancy in relation 
to this Subject. — Cases. — Conclusions. 

The Duration of Pregnancy is a subject which, in so far as regards 
the human race, is enveloped in no little obscurity. Our chief difficulty 
arises from the fact, that it is only in a very small number of cases that 
the date of fertile coitus can be accurately ascertained; and, further, in 
the majority of these, it is probable that the data are open to doubt. 
For example, when an unmarried girl says she is pregnant from a single 
coitus, may Ave not suspect that she does so to palliate her fault, as she 
can no longer conceal her shame ; and the more closely, indeed, we in- 
vestigate this class of cases, the more convinced do we become that many 
so-called instances of pregnancy from a single act should not be admitted 
in evidence. The proof, however, which is afforded by undoubted cases 
of this nature, and that which is derived from other sources, is sufficient 
to show that there is a considerable difference in the duration of preg- 
nancy, consistent with maturity of the foetus and a normal state of the 
pregnancy from first to last. 

In the Mammalia generally, one coitus, coinciding as it does, with the 
period of rut, is generally followed by conception. This admits of obser- 
vations of an exact kind in the case of many of our domestic animals : 
by means of which, indeed, much of what is known in this domain of 
physiology has been, in a great measure, established. In 1819, M. 
Tessier submitted to the Academie des Sciences at Paris the result of a 
series of investigations of this nature, Avhich are of some interest as 
illustrating by the light of comparative physiology the question which we 
are considering. The observations were, in fact, instituted with the 
object of determining the possibility of protracted gestation in the human 
race. The following are the leading results: — 

Of 140 Cows :— 

14 calved between the 241st and tlie 266th day, 
53 " " 269th " 280th " 

68 " " 280th " 290th '' 

5 " '' 290th " 308th " 

the extreme difference between the births, in an animal in which gesta- 
tion is only a little more protracted than in women, being thus 67 days. 
An extended series of observations of a similar nature, and yielding 
similar results, was conducted by the late Lord Spencer : — 



DURATION OF PREGNANCY 



173 



Of 102 Makes : 


— 












3 foaled 


on the 




311th day, 




1 




" 




314th " 




1 




a 




325th " 




1 




li 




326th " 




2 




u 




330th *' 




47 




between 


the 


340th and the 350tli 




25 




" 




356th " 360th 




21 




" 




360th " 377th 




1 




on the 




394th day, 



day, 



the extremes in this case embracing a period of no less than 83 days. 

Of course, as regards the cases in which the birth took place much 
earlier than the ordinary period, it may be said that they were examples 
of premature delivery ; but even if, by striking them off, we remove this 
possible fallacy, there still remains a sufficiency of facts to prove that, in 
those animals, there is considerable latitude as to the exact day at which 
labor may be anticipated. And, if this be the case in animals where 
sexual excitement is in abeyance during the whole period of gestation, is 
it not even more likely to obtain in the case of women, in whom sexual 
excitement persists, and who are exposed to moral and social influences, 
and to diseases, one and all of which may act as disturbing influences, 
and thus cause irregularities in the period of delivery. And, in point 
of fact, this has been shown to be the case, by numerous examples which 
have been carefully noted by experienced observers. The usual method 
of determining the approximate duration of pregnancy, it being impos- 
sible to fix the date of conception, is to make the calculation from the 
last day on which the menstrual discharge was observed. It was upon 
this principle, and selecting those cases only in which this starting-point 
could be exactly determined, that Dr. Merriman conducted his investiga- 
tions, with the results which are quoted in almost every work on obstetrics. 
Of the 150 mature births observed by him — 

5 were delivered in the 37th week — 255 to 259 davs. 



16 
21 
46 
28 
18 
11 
5 



38th 

39th 

40th 

41st 

42d 

43d 



—260 to 266 
—267 to 273 
—274 to 280 
—281 to 287 
—288 to 394 
—295 to 301 



and 



44th, the latest being the 306th day. 

reliable table a difference is shown be- 
The following table, consisting of 500 



In this most interesting 
tween the extremes of 51 

cases, by Dr. James Reid, is of no less interest, and is calculated like 
that of Merriman, from the last day of menstruation. 

Of the 500 cases — 



23 were delii 


-ered in 


the 37th week— 255 to 259 


48 




38th 


' —260 to 266 


81 




39th 


' —267 to 273 


131 




40th 


' —274 to 280 


112 




41st 


' —281 to 287 


63 




42d 


' —288 to 294 


28 




43d 


' —295 to 301 


8 




44th 


' —302 to 308 


6 




45th 


' — 309 to 315 



174 DURATION OF PREGNANCY. 

the difference between the extremes being in this case no less than 60 
days. 

The results yielded by these two tables prove that, calculating in this 
manner from the last day of the last menstruation, considerable varia- 
tions in the duration of pregnancy seem to occur. But such seeming 
variations must be viewed with caution. Our calculation is not here, as 
in cows and mares, from the very day and hour of coition, but is made 
in full knowledge of the fact that conception may have occurred on any 
one day of a period extending over more than three weeks. Such con- 
clusions as may be admitted, upon an analysis of the cases of single coitus 
in the human species which are on record, tend to show pretty clearly 
that, although the range is less than in the lower animals, there is an 
undoubted variation within certain limits. Dr. Reid, in a series of papers 
from which the above table was taken, gives an analysis of 43 cases of 
single coitus which he had collected ; but as we entertain grave doubts 
of the accuracy of such tables, for reasons already stated, we refrain 
from quoting it in extenso. According to it, delivery took place in from 
260 to 800 days, a range of no less than 40 days, and the average dura- 
tion of gestation is shown to be about 275 days. 

The facts above cited seem to show that the question of the duration 
of pregnancy is one which is of the highest importance, not only in an 
obstetrical, but in a legal sense ; and it is indeed upon the facts estab- 
lished by scientific and obstetrical research, and the opinions which are 
founded upon them, that the laws bearing upon the subject have been 
framed, and are interpreted in courts of law. One of the most interest- 
ing cases of this kind on record is the well-known Gardner peerage case, 
of which the following is a brief outline : — 

" Lord Grardner parted from his wife on board of his ship on the 30th of January, 
1802, and, having proceeded to the West Indies, did not see her again until the 11th 
of July following. Lady Gardner had been liv^ing in open adulterous intercourse with 
a Mr. Jadis, and on that account his Lordship obtained a divorce after his return, and 
subsequently contracted a second marriage. The case carae before the House of Lords 
in 1825, when Allan Legge Grardner, the son of Lord Grardner, by his second wife, 
petitioned to have his name inscribed as a peer ou the Parliament Roll. Another 
claimant, however, appeared in the person of Henry Fenton Jadis or Gardner, who 
alleged that he was the son of Lord Gardner, by his first, and subsequently divorced 
wife. He was proved to have been born on the 8th of December, 1802, and the ques- 
tion in view of the above facts simply was (as the possibility of the pregnancy dating 
from July was not put forward) whether a child born 811 days from possible inter- 
course, could have been the child of the deceased Lord Gardner. The medical evi- 
dence, as, unfortunately, it too often is in such cases, was very contradictory, but is 
particularly interesting as bringing out the opinions of the greatest obstetrical autho- 
rities of the day. Sir C. Clarke, Dr. Gooch, and Dr. Davis stated their belief that 40 
weeks (280 days) is never exceeded, while, on the other hand, Drs. Blundell, Con- 
quest, and Granville asserted that this period was in some cases undoubtedly exceeded, 
and to such an extent that they were warranted in admittiug the possibility of the 
claimant, Henry Fenton Jadis, having been a ten and a half months' child. Their 
Lordships found that the elder claimant was illegitimate, and that, consequently, the 
son of the second marriage was Lord Gardner. It must be admitted, however, that 
the moral evidence in thds case had probably more weight than the medical." 

Since this decision, the attention of the profession has been much more 
carefully directed to this subject, and probably no one at the present day 
would venture to assert that 280 days is the ultimiim tempus pariendi 
which some legal authorities supposed it to be. Were we able to date 



MEDICO- LEGAL. CASES. 175 

from the moment of conception, which under no circumstances is possible 
to us, we could soon collect sufficient data to guide us in future. But we 
must not forget that, even in those cases in which the calculation is made 
from a single coitus, the time of insemination does not necessarily mark 
the time of fecundation^ and there is good reason to believe, from what 
has been observed in the lower animals, that some days may elapse be- 
fore the fertilizing principle encounters the ovum. Then, again, if we 
date from menstruation, we must admit the possibility of irregular men- 
struation prior to impregnation, in which case conception may occur six 
weeks or more after the last menstruation. And if we admit this, as we 
tacitly do in cases of married women who carry the child longer than 
usual, we are bound in common fairness to allow the same argument to 
those who wish to prove the possibility of protracted pregnancy. The 
following instance, from the writer's case book, will serve to illustrate 
this : — 

" Mrs. P., who before had borne one child, ceased to menstruate on the 11th of Sep- 
tember. On tlie 23d of December, slie had slight hemorrhage and other symptoms of 
threatened abortion. Nothing solid came away, and she was confined strictly to bed 
until all the symj)toms had disappeared. Previous to this, she had had morning 
sickness. In the course of the month of February, she felt motion, but did not note 
the date. Development went on as usual, and she enjoyed excellent health. 

" On the 17th of July I visited her, being somewhat astonished at the duration of 
the pregnancy. On examination I felt the outline and feet of the child quite distinctly, 
the latter moving vigorously in the right hypochondriac region, where the movements 
had subjected the mother to much annoyance. The os uteri was patent, so as to ad- 
mit the point of the finger, and was quite cushiony and soft. The cervix was short, 
but quite perceptible. The presenting part could not be reached by the finger. On 
the 22d of July, 314 days from the last menstruation, a male child was born of average 
size and quite healthy." 

In this case menstruation was habitually irregular, and there was often 
an interval of six weeks between the periods. If we assume therefore 
that impregnation occurred immediately before a menstrual period was 
due, that is, after an interval of six weeks (42 days), from her last men- 
struation, this would make the duration of pregnancy exactly 273 days. 

The following case is of a somewhat similar nature, but is further in- 
teresting as affording an illustration of what we believe to be in many 
cases an essential element in determining the probable duration of preg- 
nancy. The sensation of quickening is generally, as has been observed, 
perceived by the mother a little before the middle of pregnancy, and 
should always be accurately noted, if possible. Were this done in every 
case, it would serve to correct errors which may arise from calculations 
based exclusively on the last menstruation. Had it been done in the fol- 
ing instance, some trouble and anxiety might have been saved; and the 
remark might possibly apply with equal force to many of the so-called 
examples of protracted gestation: — 

Mrs. M., who had previously borne eight children, ceased to menstruate on the 
13th of September. For some months after this she suffered much from spasmodic 
asthma, which seemed to be associated with the pregnancy, of the existence of which 
she was for some time doubtful. The movements were said to be less vigorous on 
this than they had been on former occasions, but in all other respects she went on 
well, the asthma becoming progressively less as the pregnancy advanced. The 
calculated time having long passed, and a more careful questioning having been 



176 DURATION OF PREGNANCY. 

adopted, it was found that quickening dated Jrom the first week in March at soonest. 
Only one menstruation had occurred since her former pregnancy. 

July 24th. — On examination,, the os is found to be patent. A few pains have 
occurred. Head easily reached and presenting. 

July 31st. — Child born at 5 A. M., 322 days from the last menstruation. 

If impregnation had not occurred in this case, we may suppose it 
possible, if not probable, that the second menstrual period after the 
former confinement would have taken place between six and seven 
weeks after the first, and that impregnation had occurred immediately 
before this — say on the 24th of October, or 280 days before birth. 

The last case which Ave shall cite in illustration of this subject is one 
of special interest, inasmuch as it is calculated from a single coitus under 
circumstances which leave no room for doubt as to the facts, and in 
which the pregnancy was unusually prolonged : — 

The subject of the case in question, Mrs. R., had previously had seven children, 
one having been a transverse presentation, and several having been delivered with 
the forceps. Her general health being indifferent, she dreaded greatly another 
pregnancy, and, on that account, absented herself from her husband's bed. In the 
month of March the latter went on a visit to the country, where Mrs. R. visited him 
for a single night, circumstances having arisen which obliged her to go to the Con- 
tinent, where she remained for two months. The date of this visit was the 2d of 
April, and before her return home she was convinced by previous experience that 
she was pregnant. The date of the last menstruation was a little uncertain, but 
was about the 27th of March. To the astonishment of every one who knew the 
circumstances, the pregnancy continued tar beyond the ordinary limits, until, on 
the 22d of January, she was delivered of a very large male child weighing 12 lbs. 
3 ozs., 295 days from what we believe to have been beyond all doubt a solitary 
coitus. An interesting point in the case was the great size of the child, indicating, 
as it might be, that it had been retained within the womb beyond the ordinary 
period of maturity. 

Many writers, among them Scanzoni, maintain, and some observations 
seem to confirm their view, that the rate of intra-uterine development is 
not always the same ; and that children born mature at an earlier period 
than usual are to be described as exceptional (^Graviditas Proicox), 
while the contrary class of cases are those in which, development being 
slow, maturity is not reached until a period considerably beyond the 
average [Graviditas Serotina). 

The facts just stated furnish a general confirmation of the observa- 
tions of those whose conclusions are embodied in the tables which we 
have given. The maximum, according to Reid, is 293 days, as deduced 
from his cases of single coitus ; our own case above quoted is 295 ; and 
Merriman's maximum of 305 days from the last menstruation will, if 
calculated from the probable time of conception, give about the same 
result. In Scottish Law, and in the French Code, the period of 300 
days is fixed as the utmost possible limit, and in Prussia 301, so that, in 
these countries, the child of a woman who is delivered 302 days after 
the death or proved absence of her husband is declared illegitimate. 
Difficult as it is, and always must be, to fix precisely the limit, we are 
inclined to think that these laws are just; for while it is the object of 
the law, from one point of view, to protect the innocent offspring from 
the brand of illegitimacy, if it be possible to do so, it is in like manner 
the duty of those who administer the law not rashly to confer the posi- 
tion and privileges of legitimacy upon the fruit of adulterous intercourse. 



PROBABLE PERIOD OF DELIVERY. 177 

In English Law, no period or limit is fixed, and cases, when they arise, 
fall to be decided in the light of the medical evidence of experts, and of 
the moral and collateral aspects of the case. In America, a more liberal 
view is taken, to judge from some legal decisions which are quoted by 
Taylor, where paternity was held to be proved in two cases, the duration 
of the pregnancy from coition being shown in one to be 313, and in the 
other 317 days. It is possible that the American views on this subject 
may have received their color from the extreme views entertained by 
one of the most eminent obstetricians in that country, Dr. Meigs, of 
Philadelphia, who has expressed a belief that gestation might continue 
for a year, or even more. 

With reference to what has been said as to the probability of 300 
days being a liberal interpretation of a law of nature, it must not be 
forgotten that some very able obstetricians in this country have ex- 
pressed a different opinion. The names of Simpson and Murphy are a 
sufficient guarantee that the cases cited by them, on which they found 
their opinion that pregnancy may be prolonged considerably beyond the 
period named above, are free from the suspicion of careless investigation; 
but, on the whole evidence before us, we conclude that the extreme cases 
must be disallowed, as the sources of fallacy are too numerous to warrant' 
us, without clear evidence, in sanctioning the extension of the limit beyond 
300 days.^ 

Speaking in general terms, pregnancy may be stated as lasting, under 
ordinary circumstances, for nine calendar months — from 273 to 276 
days, according to the length of the months which intervene. But, as 
we are ignorant of the date of conception, and can only make the above 
calculation under very exceptional circumstances, some other mode has 
to be adopted in practice. It is a matter of some importance to the 
practitioner, and one on which his comfort in no small measure depends, 
to be able to forecast his obstetrical engagements ; and this subject is, 
on that account, to him one of special interest. A long series of careful 
examinations, conducted by independent observers, seems clearly to show 
that the period of impregnation is usually about a week after the cessa- 
tion of a menstrual period. A ready method of reckoning, which is 

1 Some reliable information, in regard to this subject, may, as we believe, be 
derived from the observation of pregnancy in Jewish women. The author is mainly 
indebted to a very able physician and accoucheur of that persuasion for the following 
information. Among Jews, the sexes are separate during menstruation, and for 
seven clear days thereafter. The shortest period allowed for menstruation is five 
days, even should it last only for an hour or two, so that the minimum period of sepa- 
ration every month is twelve days: and, 'in anything approaching menorrhagia, of 
course much longer. This law is observed by the vast bulk of the Jewish women ; 
the exceptions are very few. After the period of separation, whatever that may be, 
the woman, besides an ordinary bath for cleansing purposes, must take what is called 
the " bath of purification." She simply dips in this, but does not. wash. This gives 
a fixed day, from which a Jewish woman reckons, as she knows the day she went to 
the bath, and calculates accordingly. Any one who may have an opportunity of 
making observations in this direction will find, 1st, that Jewish women calculate 
more accurately as to the duration of pregnancy ; 2d, that, according to their exj^eri- 
ence, the duration of pregnancy seems to be rather less than is usually supposed ; 
and, 3d (although this has less to do with the subject more immediately under con- 
sideration), that, as has been observed by a late writer in Glermany, this frequent 
and protracted abstention from sexual intercourse may be admitted as a possible 
cause of the undoubted vitality of the Jewish race. 
12 



178 



DURATION OF PREGNANCY 



founded on this belief, is recommended by many German authors, and 
is very generally practised by nurses in this country. It consists in 
taking the date of the last menstruation, reckoning three months back, 
and adding seven days. For example, a woman has ceased to men- 
struate on the 8th of June ; three months back (or nine months for- 
wards), gives the 8th of March; to this add seven days = 15th of 
March, which will be found, in a large number of cases, to be within a 
few days of the actual time of delivery. 

For greater exactness, as well as for the purposes of general scientific 
accuracy, it is better to make the calculation in such a manner as may 
enable us to compare one case with another, and at the same time reduce 
possible error to a minimum. This is done by calculating in each case 
280 days, or ten lunar months, from the last menstruation, which is 
equivalent (by deducting seven days) to nine calendar months from the 
assumed date of conception. This calculation, simple as it is, implies a 
certain amount of trouble, to reduce which various tables have been con- 
structed. Such tables, however, as are given by Naegele, or by Murphy, 
after Dr. Ryan, are too elaborate to be of any real practical every-day 

use, and to read them re- 
quires almost as much trou- 
ble as to make the original 
calculation in each case. A 
much more useful and satis- 
factory one is the following, 
which is very easily read, 
and from which the calcula- 
tion necessary may be made 
in a few seconds. 

Around the circle are ar- 
ranged, in their order, the 
months in the year, with the 
number of days in each. 
The number placed below 
each month gives the num- 
ber of days which must be 
added to the nine preceding 
months in order to make up 
280 days. If the month of 
February in a leap year is 
by the number in brackets. 
280 days from the startins;- 




To calculate the Duration of Pregnancy. (After Schultze.) 



included in a pregnancy, it is estimated 

We reckon, in order to find the next 
point (the last day of menstruation), nine months forwards (or more 
simply, three months backwards), and add to the date thus reached the 
number standing below the name of that month. 

Example 1. — Last menstruation, the 10th of February, count three 
months back = November 10th + 7 = November 17th (in leap year, 
November lOth -|- 6 = November 16th). 

Exam2:)le 2. — Last menstruation, 24th March, = 29th December, = 280 
days. 



PROBABLE PERIOD OF DELIVERY. 179 

Example 3. — Last menstruation, 30th September, = July Tth, = 280 
da vs. 

Example 4. — Last menstruation, 31st May, = March Tth -f 280 
days. 

The last example shows how to proceed when, at the end of the 
month, there may be a doubt as to the calculation. 

The 31st of Februarv is equivalent to the 3d of March which + 4 = 
280 days. 

An equally simple calculation may be made when, in medico-legal 
investigations, we want to calculate backwards from the day of birth to 
the probable cessation of the menses 280 days previously. In this case, 
we count three months forwards, and subtract the number standing under 
the birth-month. 

Example 1. — Birth, 31st October, = Menses, January 31st, — T = 
January 24th, or 280 davs. 

Example 2.— Birth, 20th April, = Menses, July 20th,— 6 = July 
14th, = 280 days. 

Impregnation may take place at any time during an inter-menstrual 
period. It is believed, however, that the time at which it most fre- 
quently occurs is about seven days after the last menstruation, and that 
the epoch next in point of frequency is immediately before what would 
have been the succeeding menstrual period. It will be observed that we 
have thus a range of three weeks within which impregnation may occur, 
even when the menstruation is quite regular, and this fact serves to ex- 
plain, as we believe, the great majority of those cases in which a woman 
appears to carry the child for three weeks beyond the calculated time. 
Indeed, when a woman goes one week beyond the 280 days, we have 
come to look upon it in practice as by no means unlikely that she will 
carry her child for fourteen days more.^ ^ 

The errors which arise from this method of calculation are of such 
frequent occurrence, that we find it of great advantage, when practicable, 
to correct this observation by another, as has already been incidentally 
observed — to wit, the quickening. In regard to this sign of pregnancy, 
there certainly exists much self-deception on the part of women, and, 
moreover, it is, as Dr. Reid remarks, seldom that they can tell us the 
exact day on which they first feel it. The vulgar belief is that the 
period w^hen it is first felt indicates the middle of pregnancy, or four and 
a half calendar months ; but the opinion of the most experienced accou- 
cheurs is, that it is, as a rule, perceived about the end of the fourth 
calendar month, or about a fortnight before the middle of the term. 

About the seventeenth or eighteenth week, therefore, maybe set down 
as the most usual period. Its value, as a sign of the duration of preg- 
nancy, is unfortunately much diminished by the uncertainty of the period 
at which it may for the first time be experienced; but, still, its value is 
very considerable in this way, that, if we have a case to deal with of 
apparently protracted pregnancy, it is unlikely that any considerable 
error should arise both as regards the quickening and the last menstrua- 

1 This term of 2S0 days is of special interest from another point of view, as mark- 
ing the tenth menstrual period from conception. (See " Causes of Labor," Chapter 
XV.) 



180 SUPERF(ETATION. 

tion in the same case. By this precaution, therefore, the risk of miscal- 
culation is certainly diminished. 

When, as is usual in midwifery practice, the services of the accoucheur 
are engaged beforehand, he should, for his own satisfaction, uniformly 
ascertain the date of the last menstrual flow, and not be content with the 
scanty information usually given that she expects her confinement 
" early in the year," or " about the middle of June." Having ascer- 
tained the fact and noted it, he must then inquire as to the quickening, 
and if the information is sufficiently clear, he must note that also. Or, 
if the woman has not yet arrived at the period of her pregnancy when 
this sign manifests itself, she must be requested to make an accurate 
note of her quickening, with a view to the subsequent information of her 
medical attendant. With the facts thus disclosed before him, he may 
then, by an application of the principles already laid down, make a cal- 
culation, which with ordinary care and discrimination, will rarely mislead 
him. 

Supeifoetation. — It is generally, though not universally, admitted by 
those who have devoted most attention to the subject, that it is quite 
possible for one impregnation to succeed another, in the same pregnancy, 
within a certain limited period, and it is all but proved that, in this 
manner, twin pregnancies do occasionally occur. This is not, however, 
superfoetation, but merely superfecundation ; the essential distinction 
between the two being, according to Scanzoni, that the former must be 
held as occurring after the period at which the decidua vera and decidua 
reflexa come into close contact. It is quite certain that the orifice of 
the Fallopian tube remains, during the early months of pregnancy, quite 
patent ; and that the mucus plug in the os internum does not hermetically 
close the cavity. In fact, the anatomical conditions are such that, but 
for the fact that the maturation of ova does not usually go on during 
pregnancy, the difficulty w^ould rather be to discover why superfecunda- 
tion was not more common. Physiologically, the real impediment lies in 
this fact, that the highest function of the ovary remains in abeyance from 
the period of conception till some time after delivery. If, therefore, 
ovulation should exceptionally go on — which Dr. Matthews Duncan sup- 
poses may be indicated by exceptional instances of menstruation during 
pregnancy — there is no difficulty in admitting the possibility of superfe- 
cundation under such circumstances. 

It is otherwise with Superfoetation, the possibility of which has been 
vigorously opposed by Wagner, who termed it a physiological impossi- 
bility ; and by most of the modern English writers, among whom we may 
mention Drs. Ramsbotham and Churchill. The idea implied is, that a 
woman who already bears within her womb a living foetus may, at a 
stage of pregnancy more advanced than that at which the two deciduae 
come in contact, again conceive, and thus carry simultaneously the fruit 
of two conceptions, between which there must be a considerable interval. 
A careful analysis of the so-called cases of superfoetation, and especially 
of the older cases, shows conclusively that, in most of them, the phe- 
nomena were quite consistent with the idea of ordinary twin pregnancy. 
Numerous cases are on record where, abortion having taken place, one 
twin has then been expelled, while the other has gone to the full time. 



SPPERFCETATIOX. 181 

Others, again, occasionally occur in which a mature child and a small 
withered one are born together. But it needs no argument to show 
that, although instances such as these may excite surprise among the 
ignorant, they are quite in keeping with what is known of the physiology 
of twin pregnancy. A number of the recorded cases are so obviously to 
be accounted for in this way, that we are almost tempted to refer, with- 
out any further investigation, all such to the same category. But an 
impartial consideration of the numerous examples which have been ad- 
vanced in support of superfoetation will not permit such a summary treat- 
ment of the subject. 

Among the cases frequently quoted, is one which was published in the 
" Transactions of the College of Physicians." 

" Mrs. T., an Italian lady, who was married to an Englishman, was delivered of a 
male child at Palermo, on the 12th of November, 1807 ; and on the 2d of February, 
1808, she was delivered of a second male child," Both children were said to have 
been born perfect, but a careful analysis of the whole facts as disclosed, seems to show 
that tlie case in all probability corDes under the class of twin pregnancies. Certain 
doubtful circumstances regarding the first infant, coujiled with the fact of its early 
death, seem to point to the conclusion that it was born immature." 

Dr. Mobus of Dieburg reports a similar case, the narrative of, and re- 
marks upon which we take from Taylor's well-known work on Medical 
Jurisprudence. 

"A healthy ma rr^W woman, about thirty-five years of age, was safely delivered of 
a girl on the 16th of October, 1833. The child is described as having been well 
formed, and having borne about it all the signs of maturity. This woman, it is to be 
observed, had previously had several children in a regular manner. Soon after her 
delivery, and the expulsion of the placenta, she felt, on this occasion, something still 
moving within her. On examination, the mouth of the uterus was found completely 
contracted, and the organ itself so drawn up as to render it difficult to be reached ; 
but the motioiis of a second child were still plainly distinguishable through the 
parietes of the distended abdomen. Her delivery was not followed by the appearance 
of discharge (lochia) or by the secretion of milk. The breasts remained tlaccid, and 
there was no fever. On the ISth of November, thirty-three days after her first confine- 
ment, this woman, while alone and unassisted, was suddenly delivered of another 
girl, which, according to Dr. Mobus, was healthy, and bore no sign of over-maturity 
about it. The reporter alleged that this case most unequivocally establishes the doc- 
trine of superfoetation. The two births took place at an interval of thirty-three days, 
and the two children were, it is stated, when born, equally well-formed and mature ; 
but Dr. Mobus did not see the second child until twenty-four hours after birth. This 
may, however, have been a twin case, in which one child was born before the other. 
Dr. Mobus considers that the first child was born at the usual period of gestation, it 
being described as mature ; and that the other, thirty-three days after that period, 
having been, in his view, conceived so many days later than the first child. If, how- 
ever, we imagine that in this, as it often happens in twin cases, one twin was more 
developed than the other, and that the more developed Avas the first expelled ; or 
that it is not always easy to compare the degree of development in two children, 
when one is born before the other, and the two are not seen together, we shall have 
an explanation of the facts, without resorting to the hypothesis of a second conception 
after so long an interval. As to the signs of over-maturitij alluded to, they are not met 
with. If we are to believe authentic reports, a child born at tiie thirty-ninth week 
cannot be distinguished from one born at the forty-third or forty-fourth week, and 
children born at the full period vary much in size and weight. A longer time may 
be required to bring children to maturity in some women than in others ; and in a 
woman with twins, it is well known that two children may arrive at the same degree 
of maturity within different periods — one requiring perhaps several weeks longer 
than the other for its full development." 



182 SUPERFCETATION. 

In a most interesting paper by Dr. Bonnar of Cupar-Fife,^ a number 
of cases are given in whicli children, born in wedlock, succeeded each 
other with very unusual rapidity. The question of superfoetation is here 
looked upon from a diiferent point of view, in reference more particularly 
to the period after parturition, at which the female procreative powers 
are again capable of exercising their functions. Dr. Bonnar gives three 
cases, all occurring in families of rank and position ; but we do not think 
it necessary to repeat the names, as some of the parties are still alive. 
In these cases, there intervened between the two deliveries 182, 174, 
and 127 days, and all the children were sufficiently developed to be 
reared, and, without exception, to reach maturity. How are we to ex- 
plain these facts ? We know that impregnation may occur within a very 
short period of delivery, long before the mucous membrane has gone 
through the process described by M. Robin, and become restored to its 
normal state. But, in the case last mentioned, this would only give 
about four calendar months from an impregnation assumed to date from 
six days after the last delivery, an age at which it would not be possible 
to rear the child, even upon the assumption of its being a case of so- 
called graviditas froecox. If we reject this theory, and yet admit the 
facts which we believe to be beyond question, there is only one other 
way of accounting for them, and that is to admit the possibility of super- 
foetation. 

Now, in regard to much of what has been urged in evidence against 
the possibility of superfoetation, it must be admitted that it is either 
irrelevant or inconclusive. Many, even of those who admit the proba- 
bility, within certain limits, of superfecundation, assume that a new con- 
ception is impossible — say in the second or third month — on account of 
mechanical impediments which exist so soon as the decidua is formed. 
We know, of course, that the complete development of the decidua re- 
flexa is a barrier to the formation of another embryo within the pouch 
which it forms ; but the researches of Coste most conclusively show, as 
has already been mentioned, that neither the Fallopian tubes nor the 
cavity of the cervix are closed so as to prevent communication between 
the vagina and the ovary. Or, to speak more plainly, there is no me- 
chanical, nor, if the function of the ovary be not arrested, is there any 
physiological impossibility that ^ new ovum might be fertilized, at any 
period prior to that at which the decidua vera and the decidua reflexa 
come into contact, and be developed in a special decidual sac. But some 
of the last cited, if they are to be taken as cases of superfoetation, 
would seem to point to a new impregnation at a period later than that at 
which the the two decidual layers come into contact ; a difficulty which 
is ingeniously got rid of by Dr. Matthews Dancan, who says, " if we 
suppose, in an instance of this kind, that the first child is born prema- 
turely, but Avithin the limits of viability, we thus gain two months; and, 
if impregnation may take place between two and three months after con- 
ception, we have thus four or five months of interval accounted for between 
the births of successive viable infants." 
It is admitted on all hands that superfoetation may take place in the 

' Edinburgh Medical Journal. January, 1865. 



SUPERF(ETATION. 183 

course of extra-uterine pregnancy. This, taken in connection with the 
facts hitherto ascertained with reference to menstruation during preg- 
nancy, seems to indicate pretty clearly that the function of the ovaries 
is not necessarily interfered with in the course of gestation ; but, at the 
same time, cases of this nature must be considered as standing by them- 
selves and not affecting directly the ordinary question of superfoetation. 

[It cannot be said that superfoetation is generally admitted as possible 
after an extra-uterine conception. AYomen have repeatedly conceived 
while carrying a child, developed outside of the uterus, but we are aware 
of no facts which prove that a uterine impregnation is possible, between 
the time that the misplaced conception occurs, and the complete restora- 
tion of the woman from the pseudo-puerperal condition, which follows the 
death of the child and the false labor, wdiich occur at or near term in 
extra-uterine pregnancy. 

The history of extra-uterine pregnancy, contrary to the opinions ex- 
pressed by the author, appears to show that the function of the ovaries 
is interfered with during the course of gestation. It is onh^ after the 
completion of this, and the restoration of the woman to the non-puerperal 
condition, that she can conceive while carrying an extra-uterine child. 

An example of this is reported by Montgomery, in which, while the 
product of an extra-uterine gestation remained encysted within the abdo- 
men, the woman bore three children, one of whom lived. A similar case 
has been recorded by Dr. Steigertahl ; and another still more interesting 
by M. Cliet, of Lyons, in which a woman died suddenly, and, upon dis- 
section, an extra-uterine foetus of five months was found in the abdomen, 
while a foetus of three months occupied the uterus. 

In another group of cases, of which many are on record, a second 
impregnation takes place, and development goes on within the unoccupied 
cavity of a double uterus. Of these, few present features of greater 
interest than one which was brought under the notice of the author by 
Dr. J. Harris Ross, of Brighton. It was embodied by him in his gra- 
duation thesis at the University of Glasgow in 1871, and was subse- 
quently published in the Lancet. The following is Dr. Ross's report: — 

''Mrs. C . the subject of these remarks, is a woman aged thirty-three. She 

has been married fourteen years ; and previous to the circumstances I am about to 
relate, had been delivered of six children. With the last three I was the medical 
attendant ; but had never before bad the opportunity of examining the uterus, as 
the child on each occasion was quite at the outlet of the vagina when I arrived at 
her house. With the exception of once (when she was prematurely delivered of a 
seven months' child) the labors were all natural, and she always made a good 
recovery. 

" She sent for me in May, 1870, as she had considerable hemorrhage. She told me 
that she was pregnant, and that she had not menstruated since the previous February. 
On examination, I found the os uteri very flaccid and partially open, and another 
opening close to the left of it, which I supposed to be an excavated ulcer, and the 
cause of the hemorrhage. As she objected to the use of the speculum, I ordered her 
to keep the recumbent posture, and to use an astringent injection, which I sent her, 
together with some tonic medicine. In a few days the hemorrhage ceased, and she got 
about her household duties until July 16th. 

" On the morning of that day she sent for me in a great hurry. I found her with 
strong labor pains ; and on making an examination, I found a bag of membranes 
protruding from the uterus, which ruptured during my examination. After this the 
pains left her. I saw her several times in the course of the day, but the pains did 



184 IN DOUBLE UTERUS. 

not return until about nine o'clock in the evening, when they were of a very feeble 
character. On examination at this time I found another bag of membranes protruding, 
which I ruptured, as I thought it might stimulate the uterus to contract. A head 
then presented, and, after some time, the pains being very feeble, a foetus was ex- 
pelled. On again examining, a leg presented, and after a while I delivered her of a 
second foetus, and then of a double placenta — that is, one with two cords. The chil- 
dren were, I should judge, of nearer six than five months' growth. After I had re- 
moved the placenta, the patient exclaimed, ' I am sure there is another, Mr. Ross' — 
meaning another child. As the uterus felt rather bulky, I introduced my hand into 
the vagina, and my finger into the uterus, to make sure, but found the cavity quite 
empty. At this time the second opening in the uterus was plainly to be felt. The 
whole course of this labor was very different from her other ones ; the pains were very 
feeble, and the labor unduly long ; this I attributed to her having twins. 

"About a week afterwards, the patient again declared that she had another child 
in the womb ; but I pooh-poohed it, as I had made such a careful examination after 
delivery, that I felt certain I could not have left one behind. She, however, per- 
sisted in her statement. One day I went to see her, and, my hand being very cold, 
I placed it upon her abdomen, when I plainly felt the movements of a child, and on 
applying my stethoscope the foetal heart was quite audible. On examination, per 
vaginam, the two openings could distinctly be felt, when it at once dawned upon me 
that I had got a case of double uterus, with both sides impregnated at the same time. 
On introducing a sound into the apertures, there was no doubt they both opened into 
a cavity or cavities, but, as she was still pregnant, I did not then push the matter 
further. When laid flat upon her back the tumor in the abdomen was decidedly 
more to the right than the left side. As there was now no doubt about her being 
pregnant, I told lier to send for me directly she was in labor. 

"She went on well until the morning of October 31st, when she sent for me at 
6 A. M. On my arrival, I found the head on the perineum, with the membranes 
protruding. I ruptured them, and delivered her of a female child of full growth 
in about a quarter of an hour afterwards. On examining the uterus (after removal 
of the placenta) I could get my thumb into one opening, and, by a little manipula- 
tion, my finger into the other, and could distinctly feel a septum between them. 
She stated that she had menstruated three times since her miscarriage of twins in 
July. Both mother and child made a good recovery." 

The conclusions, then, with reference to this subject, at which we 
think we are justified in arriving are — 1st, That, in regard to Super- 
fecundation, this is a phenomenon the existence of which there is no 
reason to doubt ; 2d, That, in so far as cases of double-uterus and extra- 
uterine pregnancy are concerned, Superfoetation is established beyond 
question ; and 3d, That, with respect to other cases (to which alone, 
perhaps, the terra Superfoetation should properly be applied), a large 
number of recorded cases are merely twin pregnancies. A strong pre- 
sumption is, therefore, established that, up to the period when the 
decidua reflexa comes into contact with the decidua vera, and, probably, 
until the two have become intimately adherent, there is a possibility of 
a new impregnation. Beyond this period we believe it to be impossible. 



TWIN PREGNANCY. 185 



CHAPTEE XI. 

PLURAL PREGNAISTCY.— EXTRA-UTERINE PREGNANCY. 

Plural Pregnancy. — Mode of Impregnation. — Twins : Disjjosition of the Mem- 
branes and Placenta in: Diagnosis of: Relation of to Super foetation. — Trip- 
lets, etc. — Extra-Uterine Pregnancy. — Varieties of: Ovarian: Tubal: 
Tuho-Ovarian : Ab domino- Tub al : Tubo-Uterine, etc.: Abdominal. — Causes 
of Extra-Uterine Pregnancy. — Development of the Ovum and its Coverings — 
Sympathy of the Uterus. — Symptoms. — Progress of in Different Varieties: 
Rupture of the Sac : Peritoneal Inflammation : Discharge of Foetal Debris. — 
Terminations. — Treatment. 

The term Plural Pregnancy may be held to include all cases in which 
two or more germs are fertilized, simultaneously or nearly so, and are 
together developed within the uterine cavity. The products of concep- 
tion in these cases are termed twins, triplets, quadruplets, etc., according 
to their number. It has been observed that certain women are peculiarly 
prone to plural conceptions, that those, for example, who have once borne 
twins are much more likely to carry two children again than those who 
have not ; and facts are not wanting to show that, in some instances at 
least, there is a marked hereditary tendency. Whether such pregnan- 
cies are or are not the result of separate acts of insemination is a question 
in regard to which we cannot venture beyond conjecture. Many facts, 
such as the birth of twins of different color, have been observed, which 
seem to show that successive acts within a limited period may be the 
cause of the impregnation of separate ova. But it is in the highest 
degree improbable that this is always the case, for there is no reason to 
believe that, if the semen comes into contact at the same time with two 
mature ova, one only is to be fecundated, and the other passed over. 
Indeed, in cases of double yolk, to which, as we shall see, twin preg- 
nancy is occasionally due, it is apparent that what may suffice to fecun- 
date one germ, can scarcely fail similarly to act upon the other. We 
shall not pause here to consider whether or not we are to explain the 
fact of the frequent unequal development in multiple pregnancies by the 
doctrine of superfecundation, but nothing is so common in this class of 
cases as to find one child well developed and vigorous, while another is 
weak and puny. 

Twin Pregnancies occur once in about 75 to 80 cases, and triplets cer- 
tainly not oftener than once in 5000. Cases where the number of children 
is greater are extremely rare. It was for long doubtful whether two 
embryos which were being simultaneously developed belonged to the same 
or different ova, and whether, in the last case, these ova proceeded from 
the same ovary. Modern research has in reference to these points estab- 
lished the following propositions : 1st, that two yolks are occasionally 



186 



PLURAL PREGNANCY 



found in a single ovum ; and that the germs contained in them are pro- 
bably simultaneously fertilized : 2d, that two ova may exist within a 
single Graafian vesicle, from which, on its maturity, they may escape and 
be fertilized, together or successively : 3d, that two ova may be formed 
within two Graafian vesicles in the same ovary, or one in each ovary, the 
latter of which is proved by the simultaneous occurrence of pregnancy in 
each cavity of a double uterus (see Dr. Ross's case, quoted in Chap. X.). 
In these cases, tw^o corpora lutea are found in the same stage of develop- 
ment. 

The following varieties of twin pregnancy, — the distinction between 
which depends on the arrangement of the membranes, cord, and placenta, 
■ — are those w^hich are generally observed in practice. The essential 
difference between them depends, as a little careful examination will show, 
upon whether two ova have been impregnated, or a single ovum has con- 
tained two germs. 

The cases which occur most frequently are those in which two distinct 
ova are impregnated, whether they come from separate ovaries, from tw^o 
Graafian vesicles in one ovary, or from a single Graafian vesicle. Each 
of these becomes imbedded in the mucous membrane of the uterus, and 
the decidua reflexa rises round it in the usual way. In the process of 
growth, the two tumors approach each other and come in contact, forming 

thus a partition between the two cavities, 
which originally consists of six layers, the 
decidua, chorion, and amnion, proper to each 
embryo. It would seem, however, accord- 
ing to the observations of Guillemot and 
others, that the decidua forms a very thin 
layer in the partition, or is absorbed, so that 
the partition at maturity consists of four lay- 
ers only, consisting of the amnion (3 3) and 
the chorion (2 2) on each side, the whole mass 
being enveloped in a single decidua (i i). 
In these cases the placentae, developed, as 
will be remembered, on the maternal and 
foetal sides, from the decidua and chorion respectively, are sometimes 
completely separated, the one from the other. In other instances, again, 
they are fused together into a single mass, or are united by a sort of 
membranous bridge. But, as a rule, in spite of this continuity of tissue, 

there exists no vascular communication be- 
tween the two. 

In another class of cases, which are com- 
paratively of rare occurrence, there is a cho- 
rion (Fig. 94, 2 2) common to both embryos, 
each, ho wever, being inclosed in its own amnion 
(3 3), the common decidua (11) surrounding 
the whole, as in the former case. In these 
instances there is a single placenta, and very 
frequently ramifications exist between the 
branches of the two cords. There can be no 
doubt that here there must have been impregnation of two germs within 
a single ovum 




Diagrammatic Representation of 
Partition in Twin Pregnancy (1st Va- 
riety). 




Twin Pregnancy (2d Variety). 



or, in other w^ords, they are cases of double yolk. 



DIAGNOSIS OF TWIN PREaNANCY. 187 

It occasionally occurs that Uxo embryos exist in a common amnionic 
cavity, — a fact which it is difficult to explain on any other hypothesis 
than that they orioinally belonged to the last class, and that the amni- 
onic partition in Fig. 94 is absorbed in the course of development. If 
we could admit that the doctrine propounded by M. Serres was correct, — 
that the amnion exists, in the first instance, as an independent vesicle, 
and that, subsequently to its complete development, the foetus comes into 
contact with it, and depresses its surface so as to envelop itself in a double 
layer, as takes place in the case of the serous membranes and the viscera 
which they invest, — we might be able to explain the occurrence. In the 
present state of our knowledge, however, on the subject of Ovology, we 
are at a loss to account for the presence of two embryos in one amnionic 
sac on any other theory than that which we have mentioned. But we 
cannot agree with those who pronounce it to be impossible, or irrecon- 
cilable with the views of development which have been given in an earlier 
section of this work. For, while we are constrained to admit the impro- 
bability, we cannot subscribe to the impossibility of the development of 
two embryos on a continuous surface of the germinal membrane, — both 
being included within the cavity formed, in the usual way, by the amni- 
onic folds. The two cords have generally been observed, in these cases, 
to spring from separate points of the placenta ; but they have been found, 
in a few rare instances, to spring from a common trunk, which bifurcates 
at a variable distance from the placental surface. In the cases of twin 
pregnancy in which one foetus is deprived of an important part of its 
body, it has been frequently found along with a perfect twin in the same 
amnionic sac. 

A fourth variety of twin conception is that which has been described 
by Olivier and others, under the name of moyistrosity hy inclusion. 
This consists in the presence, within an otherwise perfect foetus, of the 
elements, more or less distinct, of another, which may be situated either 
within the abdominal cavity, or beneath the skin — usually in the neigh- 
borhood of the perineum or scrotum. 

It is often possible, during the currency of a pregnancy, more espe- 
cially during the weeks immediately preceding delivery, to recognize the 
presence of twins. Generally speaking, when there is, as is usual, a 
foetus on either side of the uterus, the shape of the organ is less globular 
than usual, and there is more enlargement in the direction of the sides. 
The woman may complain of movement at separate points of the abdo- 
men — an observation which, although far from being conclusive evidence 
of the presence of twins, seems to be, in certain cases, of some practical 
value as a symptom. If the abdominal wall be thin, it may also be pos- 
sible for the accoucheur to perceive these movements by palpation, and, 
in the course of the same examination, even to recognize the presence of 
a second foetus. There is greater distension of the abdomen, and an 
aggravation of such symptoms as are the result of pressure on neighbor- 
ing organs. The pulsation of the two foetal hearts may be heard at 
different points on the abdominal surface, and there may be, as has 
already been mentioned, a want of synchronism in the sounds. Ballotte- 
ment is not practicable. The uterine souffle is unaltered. These signs 
are, how^ever, often vague and unsatisfactory, even in those cases in 



188 PLURAL PREGNANCY. 

Avhich a suspicion of twin pregnancy has arisen ; and, in the majority of 
instances, the fact of the plural pregnancy is only recognized in the 
course of labor. 

Whether as the result of superfecundation, or simply of unequal de- 
velopment, cases are very frequently met with in which the infants are 
of different size. In others, the growth of one foetus is arrested, and it 
dies. The results, in such cases, vary considerably, being influenced by 
various circumstances, among which we may assume that the mode of 
disposition of the membranes is not the least important. In a certain 
number of cases, the dead foetus is retained, but there being no access of 
external air, no putrefactive change takes place. It becomes hard, 
withered, and mummified, and in this state it may be born with the 
mature foetus at the termination of pregnancy. This may happen what- 
ever may be the nature of the partition between the two, and even, as 
some believe, in the cases in which they are in a single amnionic cavity ; 
but it is, we apprehend, likely that Baudelocque is correct when he 
assumes that, in the latter, the death of one necessarily places the life 
of the other in great jeopardy. In other instances, the dead foetus acts 
as a foreign body, or in some other way incites the uterus to contract, the 
result being usually the expulsion of the living and the dead ; or the 
dead foetus is expelled, and the uterine action being arrested at this 
point, the living one is retained, and ultimately fully developed. This 
can, for reasons which a moment's reflection will render obvious, only 
take place when each foetus is enveloped in a complete series of mem- 
branes. If there be a common chorion, and, a fortiori^ if there be a 
common amnion, the expulsion of one necessarily involves the expulsion 
of the other. In yet another group of cases of this nature, both are re- 
tained ; but when labor comes on, the mature and living child only is 
expelled, while the withered foetus remains behind, and may possibly 
occup3^ the womb for a very considerable period. The cause of the 
death of one foetus in these cases i^ not well understood, bvit, probably, 
they who believe it to be due to some form of degeneration of the placenta 
or the membranes, or to some disease in the foetus itself, are correct in 
their supposition. 

It has been observed, with reference to multiple pregnancies, that they 
frequently terminate before the full period of gestation has been reached. 
This we may assume to be due to the over-distension of the uterus, which 
excites it to contraction at a period somewhat earlier than usual. As a 
rule, both children are generally expelled in the course of the same 
labor, in some instances without even a pause in the uterine eff'ort. This 
is, however, far from being invariable, as it is not uncommon for the 
action to cease, and to return again in eighteen, twenty-four, or even 
forty-eight hours, when the uterus is thrown anew into periodic contrac- 
tions, and the labor goes on in a perfectly regular and normal manner. 
In NQvy rare cases, the interval between the two births may extend to a 
period of weeks, or even of months ; and there can be no doubt that 
many of these cases have given rise, on erroneous grounds, to a belief in 
the theory of superfoetation, the error arising from the fact that the im- 
maturity of the first child is overlooked. 

It is unnecessary to make further mention of the other varieties of 



EXTRA-UTERINE PREGNANCY. 189 

multiple pregnancy, as the observations which have been made may be 
held, mutatis mutandis^ as applicable to these also. To judge from the 
few cases in which observations have been made, it would appear to be 
rare that each foetus, the number being more than two, is inclosed in its 
own complete sac. Several cases of triplets, are, for example, recorded, 
in which one had a special sac, while the other two had a common 
amnion. In regard to the possible retention of one or more of them, 
we may well suppose, to judge from analogy, that any conceivable com- 
bination of the numbers is in this respect possible. The practical 
bearing of plural pregnancy on the progress of labor will be noticed 
hereafter. 

I^xtra-iderine Pregnancy, — Although the cavity of the womb is the 
site .which nature has specially prepared for the development of the fruit 
of conception, it occasionally happens that it goes through its character- 
istic phases of development elsewhere. Generally, in these cases, its 
growth is arrested at a stage considerably short of maturity ; but many 
instances have occurred in which the full period .of gestation has been 
reached, and some in which it has been considerably exceeded, although 
the cavity of the uterus was entirely empty, as in the virgin state. The 
ovum is, as has been shown, developed within the ovary in the Graafian 
vesicle ; and what has been observed in the lower animals leads us to 
conclude that, while yet it occupies that situation, and even before the 
rupture of the vesicle has occurred, impregnation may take place. On 
the burstmg of the vesicle, the germ is received into the infundibulum or 
pavilion of the Fallopian tube, and is thence conducted slowly through 
the entire length of the tube, until it reaches the uterine cavity, where its 
subsecjuent development progresses until the moment of delivery. Such 
we know to be the law of nature. Constituting an exception to this law, 
the ovum may, however, be arrested and take root at any point of its 
course, while the vital processes of development go on, up to a certain 
point, as actively and as efficiently as if the ovum had passed on to its 
usual site. In other cases it may deviate from its normal channel, and, 
escaping between the fimbriae of the Fallopian tubes, fall into the cavity 
of the peritoneum, to some portion of which it attaches itself. These are 
the circumstances which give rise to extra-uterine pregnancy, and cases 
as they occur are classified more or less elaborately according to the 
anatomical relations which the ovum assumes in its vmwonted situation. 
The usual division is into Ovarian, Tubal, and Abdominal cases, with 
many subdivisions, the more important only of which will be noticed. 

The existence of Ovarian pregnancy has, by Mayor, Velpeau, and 
others, been absolutely denied. The denial seems, however, to have 
been founded on the assumption, which we believe to be unwarranted, 
that impregnation is mechanically impossible without rupture of the 
Graafian vesicle. But, even if rupture has taken place, it is not incon- 
ceivable that a fertilized ovum should remain and become, at least par- 
tially, developed within the Graafian vesicles.^ This is what has been 

' This, we observe, is the view taken by Dr. John S. Parry in his exhaustive and 
able treatise, "Extra-Uterine Pregnancy, its Causes, Species, etc., by John S. 
Parry." Philadelphia, 1876. 



190 EXTRA-UTERINE PREGNANCY. 

termed the "internal" variety of ovarian pregnancy, as distinguished 
from the " external" form, in which the ovum is attached to the surface 
of the ovary. It is probable that, while the latter may more properly 
be classed as ''abdominal," or " tubo- ovarian," it is the former alone 
which should receive the name of " ovarian" pregnancy ; but it must be 
confessed that, in this sense, internal or true ovarian pregnancy involves 
an assumption which, among modern physiologists, receives little support. 

Of all the varieties of extra-uterine gestation, the most common, by 
far, is the Tubal, which, for the reasons already stated, is precisely what 
we would anticipate. The ovum in its descent towards the cavity which 
awaits it, is arrested, it may be at any one point of its course, and there 
contracts adhesions, forms its mem.branes and placenta, and is thus sur- 
rounded, in lieu of a uterus, with a sac which is formed of the dilated 
and hy per trophied walls of the Fallopian tube. For greater precision in 
description, various names have been assigned to such pregnancies, ac- 
cording to the exact point at which the arrest of the ovum takes place. 
Those quite at the fimbriated extremity of the tube, which either are 
originally, or come to be in course of time, in contact both with tube and 
ovary, are termed tuho-ovarian. When the ovum is stopped at the point 
where the tube first narrows, the fimbriae having relaxed their hold on 
the ovary, the development may take place partly within the tube, where 
the placenta will probably be situated, and partly bulging into the abdo- 
minal cavity, in which direction the growth mainly advances : to this 
variety the name tuho-ahdominal has been given. Between this point 
and the uterine wall is the situation at which the ordinary and most com- 
mon form of tubal pregnancy occurs. Several varieties have been de- 
scribed of cases in which the ovum has its seat in the immediate vicinity 
of the uterine cavity, of which the most important and interesting is the 
utero-tubal, where the ovum lodges in that portion of the tube which 
passes through the walls of the uterus. The development in such a case 
may be partly within the uterus and partly within the tube ; or, when a 
little more external, it may develop actually within the parenchyma of 
the uterus, and, if projecting into the cavity, may be invested with a 
covering of muscular fibres derived from the uterus itself. This is, pro- 
bably, the graviditas in substantia uteri of the older writers. 

Among the rarer varieties is that, of which an example is given by 
Burns, in which the placenta is found in its normal situation within the 
uterus, and the foetus within the Fallopian tube ; and, still more rare are 
those of which Hunter, JToffmeister, and Patuna have given illustrations, 
in which the foetus has been found in the abdominal cavity, and the pla- 
centa in the uterus — the two being connected by a cord which ran from 
the placenta for some distance within the Fallopian tube, and then perfo- 
rated it to join the foetus. These latter cases have been called utero- 
tuho-abdominal ; and, in reference to them, we may assume that they 
were originally cases of tubal pregnancy, in which the placenta had been 
developed within the uterus, while the foetus had escaped into the peri- 
toneum by rupture of the walls of the sac in which it had been contained. 
Another rare form has been described as subperitoneo- pelvic ; in which 
it is assumed that the ovum having been unable to enter the external 
orifice of the tube, has got between the folds of the broad ligament, and 



ABDOMIXAL PREGNANCY. 191 

there developed itself. It has been justly observed that, if this variety 
does occur, a more favorable result may be anticipated than in the other 
forms ; because, in such a situation, the debris of a dead foetus may be 
more easily and more safely removed. 

In Abdominal Pregnancy, the fertilized ovum escapes the grasp of the 
fimbria, and falls into the cavity of the peritoneum, to any portion of 
which membrane it may in fact become attached. We may thus find it 
firmly incorporated vrith the broad ligament, the intestines, the colon, 
and any other parts to which continuity of tissue permits its access. The 
essential physiological difference between an abdominal case and the 
other varieties of extra-uterine pregnancy is that, in the former, the ovum 
is without any special covering which can correspond to that which, under 
other circumstances, it derives from the tube or other investing structure. 
It grafts itself, so to speak, upon the peritoneal surface of some viscus, 
or of the abdominal wall; and if it is subsequently covered with any 
special covering, that must be the result, physiologically, of special evo- 
lution, or pathologically, of inflammatory action. 

Little has been hitherto discovered which enables us to come to a 
satisfactory conclusion, in regard to any of the above varieties, as to the 
causes of extra-uterine gestation. Many have believed that a shock or 
fright, or a blow on the lower part of the belly may give rise to it, should 
this chance to coincide with the moment of conception, and they ground 
this belief on facts which women have from time to time communicated. 
Ko single observation affords, however, to this theory, even the shadow 
of a proof, and the so-called evidence on which it rests, may perhaps be 
attributed without impropriety to that love of the marvellous which exists 
in so many minds. We cannot doubt that certain pathological conditions 
might furnish the cause ; and, in" some instances, the existence of such 
pathological conditions has been established. Inflammatory action of any 
kind, induration, pressure exercised by morbid growths, spasm of the 
muscular fibres of which the tube is so largely composed — so as to cause 
stricture — are a few of a hundred conditions which might be specified as 
2^ossible causes of the phenomena. The fact is, however, that in most of 
the cases in which a careful examination has been made, the course of 
pregnancy so alters the anatomical conditions of the chosen site, that it 
is impossible to come to any satisfactory conclusion as to the original 
condition of the parts. Some very curious phenomena have been ob- 
served, showing that the ovum is sometimes very erratic in its course. 
How otherwise are we to explain the facts observed in Dr. Oldham's cases, 
in which there was a distinct corpus luteum on one side, and tubal preg- 
nancy on the other? for we must accept, as Dr. Tyler Smith says, in 
reference to one of these cases, one of three explanations: "The unim- 
preguated ovule might have been swept by the cilia of the peritoneum 
from the right ovary to the fimbriated extremity of the left tube ; this 
would be similar to what occurs in the Amphibia, in which the ova always 
traverse the abdomen to reach the oviduct. Or the left tube may have 
reached over to the right ovary and have taken up the ovule. According 
to the third explanation it might be that the ovule had descended the 
right tube, entered the uterus, and then ascended through part of the 
left tube by an anti-peristaltic action, or by the ciliary currents which 



192 EXTEA-UTERINE PREGNANCY. 

move from below upwards." The view which Dr. Tyler Smith preferred 
in reo;ard to the case in question was the third ; while Dr. Oldham and 
Mr. Wharton Jones were inclined to accept rather the second of the 
explanations offered. 

In every form of extra-uterine pregnancy, the ovum forms its own 
membranes, and goes through the various phases of evolution in all respects 
as if the pregnancy were normal. It is therefore in every case covered 
by its own amnion and chorion, without which, indeed, further develop- 
ment were impossible. So far all cases are alike. But in regard to the 
further coverings of the foetus which, external to those just named, are 
of maternal origin, and correspond to the decidua and the uterus, great 
differences exist according to the class of extra-uterine pregnancy to which 
each case is to be referred. It is probable that in tubal pregnancy the 
mucous membrane may form, as in ordinary cases, a special envelope 
strictly analogous to the decidua ; but, whether we take this view of the 
case or not, it is clear that, in every instance, the sac within which is 
contained the foetus and its special structures, is composed of the mucous, 
muscular, and serous layers of the Fallopian tube, which become dis- 
tended, and at the same time hypertrophied, as the ovum grows. In true 
ovarian pregnancy, if such indeed exist, the sac must consist originally 
of the walls of the Graafian vesicle, and of the special coverings of the 
ovary itself; but, in the compound forms, the sac may be partly tubal 
and partly ovarian, or partly tubal and partly uterine, the covering de- 
pending simply in each case upon the site at which the ovum becomes 
arrested. 

Cases of Abdominal pregnancy differ materially from all others in this 
respect, and stand on that account in a class by themselves. The ovum 
is not in this variety arrested at any point of the canal through which 
nature intended it to pass ; but escapes altogether from that canal and 
falls naked into the great abdominal cavity, without any special covering 
whatever, unless it be some remains of the granular disk in which it was 
imbedded. Here, in the early stage at least, there can be no special 
covering, nor connection with the maternal parts other than mere juxta- 
position, the result of gravity or some other accidental circumstance. If 
the ovule has not, prior to this, been fertilized, it will no doubt rapidly 
disappear, and be absorbed with the secretions of the peritoneal surface. 
But if, on the other hand, an independent vitality has been communicated 
to it by conception, it bears the life which it contains to some point acci- 
dentally selected, and having there grafted itself upon the subjacent part, 
the essential contact between the maternal and foetal systems is estab- 
lished, and the subsequent stages of development ensue. There can thus 
be, in the first instance, no sac whatever ; and although it is not impos- 
sible that a special sac might be developed from the peritoneal surface, 
as under ordinary circumstances takes place from the mucous membrane 
of the uterus, no facts have hitherto been observed to show that the 
ovum in abdominal pregnancy has ^ny sac external to the chorion. But, 
should rupture of the membranes of the ovum occur, the embryo, which 
usually escapes into the abdominal cavity along with the liquor amnii, 
instantly becomes a foreign body ; and, by exciting inflammatory action, 
provokes the development of coagulable lymph. This, under favorable 



ABDOMINAL PREGNANCY. 193 

circumstances, may form a sac around the ovum, inclosing it now in a 
special cavity, and protecting the rest of the peritoneal surface from the 
dangerous effects of extensive inflammation, which would inevitably ensue 
from the prolonged contact of the foetal remains. 

Whatever the site may be, abdominal or otherwise, at which the fer- 
tilized ovum takes up its position, the speedy result is a marked increase 
in the vascularity of the contiguous parts. If, for example, it becomes 
adherent to the peritoneal surface of any portion of the bowel, the blood- 
vessels of that part will at once become the seat of a marked and wonder- 
ful hypertrophy. "What were before minute twigs now become large 
venous trunks, and the arterial supply is of course proportionally aug- 
mented. The vessels being projected from the embryo to the chorion by 
means of the allantois, the vascularity of that membrane is at once 
established. Those of its villi which belono; to the visceral surface undero-o 
marked development, and contract still closer adhesions with the peri- 
toneum. The whole of the tissues become at this point enormously 
developed, and thus the Placenta is formed, within which the interchange 
of gases and materials goes on smoothly and, for a time, safely. 

During the development of an extra-uterine foetus, certain changes 
more or less marked have been noticed to take place in the uterus at an 
early period of the pregnancy. These changes, in so far as they have 
hitherto been observed, seem to be identical with the preparatory process 
of which the uterus is the seat at the time of impregnation, prior to the 
descent of the ovum. They consist in a marked increase in the size of 
the organ, in an equally marked increase in its vascularity, and in the 
characteristic thickening and hypertrophy of the mucous membrane, 
which is the first stage in the formation of the decidua. 

The Symptoms of extra-uterine pregnancy are far from being definite 
and distinct. Just at first, the changes which have been mentioned as 
occurring in the uterus would, no doubt, tend to suggest the idea of an 
ordinary pregnancy. The woman may, at this time, enjoy perfect health, 
disturbed only by some of the sympathetic digestive disorders which are 
so familiar. No reliance can be placed on the cessation of the menses 
as a sign, as, from the narrative of recorded cases, it would appear that 
the discharge ceases in about the same proportion of cases as it persists, 
while, in another class, irregular uterine hemorrhage seems to be looked 
upon, if coincident with the early symptoms of pregnancy, as having a 
certain diagnostic value. Very generally, from an early period of the 
pregnancy, abdominal pain is complained of. This may take the form of 
an intermitting pain ; but it is generally constant, and confined to a cer- 
tain limited region, which maybe anyone point on the abdominal surface. 
In many cases there is, along with uterine hemorrhage, a discharge of 
membrane which is true decidua, formed as above described, and of great 
interest and importance from a diagnostic point of view. As the case 
advances and the ovum grows, considerable discomfort maybe caused by 
pressure, exercised by the tumor, directly or indirectly on neio-hborino- 
organs ; causing, for example, if the tumor should encroach upon the 
pelvic cavity, difficulty in defecation and micturition. Morning sickness, 
and the various changes which have their seat in the breasts, are ot usual 
occurrence ; and, as the case goes on, a tumor may be felt which re- 
13 



194 EXTRA-UTERINE PREGNANCY. 

sembles, more or less closely, the gravid uterus, but which is frequently 
more irregular in outline, and situated more to one side than in the 
middle line. At the proper time, quickening takes place, and is soon 
succeeded by the pulsation of the foetal heart. Should suspicion have 
arisen as to the nature of the case, it is probable that the absence at this 
time of the characteristics which are revealed in ordinary pregnancy by 
a vaginal examination might throw considerable light on the case. 

[A careful study of the clinical histories of a large number of cases 
of extra-uterine pregnancy, appears to show% that the symptoms of this 
accident are not so vague, as the statements of the author would lead us 
to believe. During the first few weeks after conception, there may be 
no symptoms to attract the attention of either the patient or her friends. 
Sooner or later, however, often at the end of the fourth week, often not 
until the end of the second month, the woman is seized with a violent 
pain, usually described as colic, and situated in the hypogastric region, 
generally on one side. This pain is very severe, and often produces pro- 
found prostration, with pallor, cold, clammy perspiration, feeble or nearly 
imperceptible pulse, and even syncope. It is generally associated with 
marked, and even very great tenderness in the lower part of the abdo- 
men, which has led some to mistake this condition for perotinitis. After 
a period of variable duration, from a few hours to one or two days in 
most cases, the severity of the pain diminishes or it may disappear entirely. 
The calm, however, is deceitful, for sooner or later another paroxysm sets 
in, and pursues the same course that the first did. These attacks of pain 
continue to recur at intervals, until rupture occurs, or until after the fifth 
or sixth month of gestation. They sometimes continue to term. 

Appearing before the pain, with it, or immediately after it, is another 
very characteristic symptom. This is metrorrhagia. The quantity of 
blood lost varies from a slight discharge to an exhausting hemorrhage. 

The occurrence of these two symptoms in a Avoman, who is herself 
firmly convinced that she is pregnant, should always lead to the suspicion 
of extra-uterine pregnancy. If in addition to these a decidua should be 
discharged en masse or in pieces, or symptoms of rupture supervene, the 
diagnosis is almost absolute. Even thus early an extra-uterine tumor can 
be discovered. At the end of the third month the child has been de- 
tected by ballottement. 

After the foetal heart can be heard, all doubts about the woman being 
pregnant are removed. It will now be found that the foetal tumor is de- 
veloped upon one side, that its contents are very superficially situated, 
and that in some, but not all cases, the sac is immovable. By vaginal 
examination the uterus is found to be displaced. The os is generally 
carried forwards and upwards, so that it is often pressed against the sym- 
physis pubis, or the anterior abdominal wall, some distance above the 
pubis. It is often reached with great difficulty, or cannot be found at all. 
At the same time an elastic or fluctuating tumor forms in the pelvis be- 
hind the uterus. The retro-uterine fulness with anterior displacement of 
the womb should always lead to the suspicion that the child is being de- 
veloped outside of the uterus, providing the existence of pregnancy has 
been established. Another important symptom is the small size of the 
uterus, which, while it becomes more or less enlarged, is not developed 



SYMPTOMS. 195 

in proportion to the duration of the gestation. Great care has, however, 
to be exercised in making this examination to avoid being misled by the 
condition of the os and cervix. During this stage the spasmodic pains 
and metrorrhagia, so often present during the first three or four months 
of gestation, are likely to have ceased. — P.] 

If the pregnancy goes on without accident or hindrance till the period 
which marks the ordinary limit of gestation, pains come on, which are 
periodic, and which are described by women who have already borne 
children as precisely similar to ordinary labor pains. " These pains," 
says Burns, " usually begin in the sac, and then the uterus is excited to 
contract and discharge any fluid it contains." This uterine effort, at the 
end of the ninth month, is a physiological fact of surpassing interest, and 
seems to us to afford strong corroborative evidence of the correctness of 
that theory which supposes that the cause of labor has its seat neither in 
the foetus nor in the uterus, but is, probably, to be found in the ovary, 
and is to be looked for generally at the tenth menstrual period after im- 
pregnation. In weighing the symptoms in a doubtful case, a fact which 
has already been mentioned in reference to the question of superfoetation 
should be borne in mind, viz. : that a second (uterine) pregnancy is quite 
possible ; and, indeed, a most striking case is quoted by Montgomery from 
Primrose, in whicli a woman went to the ninth month of her seventh ges- 
tation, when labor came on as in former occasions, although, ultimately, 
it turned out that there was a prior abdominal pregnancy. 

The cases, however, in which extra- uterine pregnancy is prolonged till 
the ninth, or even the eighth m©nth, form a very small proportion of the 
whole. It is, in point of fact, an unusual occurrence when development 
in such a case continues beyond the fourth or fifth month ; but, on the 
other hand, cases are on record, which are apparently authentic, in which 
the life of the foetus was prolonged within the abdomen for several months 
beyond the ordinary period. M. Dezeimeris, whose memoir on this sub- 
ject is justly considered as of great value, states that rupture occurs in 
more than three-fourths of all cases ; that, in the tubo-uterine variety, it 
takes place, as a rule, before the end of the second month ; in tubal, in 
the fourth month ; later in ovarian pregnancy ; and, in abdominal preg- 
nancy, not till the eighth or ninth month. The usual crisis, then, in all 
such cases, which may arrive sooner or later in their course, is rupture 
of the sac and of the foetal membranes, or of the latter alone in abdomi- 
nal pregnancies. 

The symptoms which follow rupture of the sac are of extreme gravity, 
and the result invariably is that the life of the woman is placed in great 
jeopardy. The rupture is frequently preceded by severe pains, which 
may continue for several hours. A sudden cessation of these pains is 
then observed to coincide with a notable diminution in the size of the 
tumor. This is succeeded almost immediately by pallor, dimness of vision, 
vomiting, syncope, and other symptoms which indicate profuse internal 
hemorrhage. To these succeed loss of pulse, clammy sweat, convulsions, 
and death, — or, the bleeding being arrested, the patient rallies and escapes 
the immediate dano;er of hemorrhaore. 

If, after rupture of the sac, the hemorrhage is limited in extent, or if 
something occurs to check it by favoring the coagulation of the blood, 



196 EXTRA-UTERINE PREGNANCY. 

death may not be immediate, but may, nevertheless, take place, as the 
result purely of hemorrhage, after an interval of some days ; whereas, 
if the flow of blood be effectually barred, the patient may rally, and the 
symptoms of impending dissolution may disappear. But the danger which 
has thus been averted is forthwith succeeded by another equally grave. 
The foetus, the amnionic fluid, and the effused blood, arouse violent peri- 
toneal inflammation, which rapidly runs its course, generally with a fatal 
result. Should the powers of nature be of sufficient energy to overcome 
this second assault, the effect of the inflammatory action is rather bene- 
ficial than otherwise, for the foetus now becomes inclosed in a sac, which 
is formed from coagulable lymph, and this effectually shuts it out from 
the rest of the abdominal cavity. Within the new cavity, a process of 
disintegration or modified decomposition goes on in the greater number 
of cases. The presence of the foetal debris excites anew^ inflammatory 
action, extending probably to contiguous viscera, between which and the 
sac adhesions may be established. To this succeeds ulcerative absorp- 
tion, resulting in the establishment of fistulous openings in the direction 
of the hollow viscera, or externally through the abdominal walls : or per- 
foration may take place a second time into the peritoneal cavity, with 
little hope of any result other than a fatal one. But, if the perforation 
take the direction first mentioned, we may have, for weeks, or months, 
portions of the more indestructible foetal structures, bones, teeth, and the 
like, discharged through the abdominal wall, the vagina, the rectum, the 
bladder, or even the stomach ; and, if there be more than one fistulous 
opening, we may have portions successively or simultaneously discharged 
through two or more of the channels which have been enumerated. While 
the discharge of debris is going on, the inflammatory action in the inte- 
rior of the cyst continues, and is probably aggravated by the admission 
either of the external air, or of the contents of the hollow viscera into 
which the opening takes place. Irritative fever of a severe type is thus 
often set up, and to this, those women who have been so fortunate as to 
escape the dangers already specified may succumb. 

In some instances, the course and termination of extra-uterine preg- 
nancy is very different from what has been detailed. The pressure of the 
tumor may be productive of such annoyance and pain, or may interfere 
so seriously with the functions of neighboring organs, that the woman 
sinks and dies without any rupture having occurred; or even, in so far 
as can be ascertained, without the death of the foetus having preceded 
that of the mother. Or, as in another class of recorded cases, the child 
may die before rupture of the membranes has occurred, a result which 
we must look upon as favorable in the progress of these cases. For the 
first result of this is the arrestment of placental circulation, the dwindling 
of the enlarged vessels on the mother's side, and the consequent abate- 
ment in the risk from hemorrhage to which the woman is subjected. 
Under such exceptional circumstances, it is quite possible that no rupture 
of the original sac may occur. The foetus will then be retained without 
the occurrence either of hemorrhage or peritoneal inflammation, but ulti- 
mately its remains will most likely be extruded by a similar process, and 
through the same channels as in the cases above mentioned. In some 
remarkable instances, the irritation caused by the presence of a dead 



TREATMENT. 197 

foetus has been so inconsiderable as to permit of its residence for many 
years within the abdominal cavity, without causing any alarming symp- 
tom. It is probably in such cases that the putrefactive process undergoes 
the peculiar modifications which are manifested either by a withering or 
mummification of the foetus, or by a change which seems to be closely 
allied to adipocere. In many of the recorded cases in which the foetus 
has been retained for an unusually long period, the sac would appear to 
have become the seat of calcareous deposit, w^hich, by thickening and 
strengthening its walls, may be supposed at once to protect the foetus 
from external violence, and, at the same time, to protect maternal viscera, 
by rendering its rupture practically almost impossible. Burns mentions 
a case in which he had known the foetus retained for twenty years, and 
there have been instances in which it has been retained for a much longer 
period. Women, in some of these cases, have repeatedly become preg- 
nant, and have been delivered of healthy children at the full time without 
disturbing the retained ovum. 

In regard to the Treatment of extra-uterine pregnancy, much must in 
every case depend on the stage of development and on the other circum- 
stances of the case. In so far as the early weeks are concerned, it is 
obvious that, accurate diagnosis being impossible, treatment can only be 
palliative, or directed against symptoms, the import of which we can only 
guess at. At a stage somewhat more advanced, precision in diagnosis 
is scarcely more easy ; although, could we only be certain of this, we 
cannot doubt that the resources of modern surgery might avail. If the 
sac were lodged in the pelvis, interference would very probably take 
place with the functions of the bladder and rectum, requiring close atten- 
tion to the state of the bowels, and perhaps frequent mechanical aid for 
the relief of the bladder. The attacks of pain, w^hich are of such frequent 
occurrence in all the forms, will be most certainly and satisfactorily re- 
moved by anodyne applications and by opiate suppositories or enemata, 
strict rest in the recumbent posture being at the same time enjoined, with 
careful attention to the digestive and other functions. It has been sug- 
gested by Cazeaux that, even at this early period, attempts should be 
made, by bleeding to syncope, or by electric shocks passed through the 
abdomen, to destroy the life of the foetus. Were this practicable, it 
would be sound treatment, in view of the probabilities of the case, to cut 
short the existence of the foetus; but we apprehend that the result looked 
for cannot be counted upon. It has also been recommended to perforate 
the sac by trocar from the vagina, should this be practicable, a step to 
which Scanzoni lends his powerful advocacy ; and we see no reason to 
doubt the propriety, in many cases (if only diagnostic difficulties were 
overcome) of exhausting the liquor amnii by means of the aspirator. 

When the period of expulsive effort arrives, it comes to be a question 
whether in any case we may interfere with a view to the relief of the 
patient by immediate delivery. The cases, doubtless, in which operative 
interference may be resorted to with the greatest prospect of success, are 
those in which the foetus is felt through the vagina, and the nature of the 
case is distinctly made out; and, an additional argument in favor of ope- 
ration will doubtless be aiforded by proof of the life of the child. Be- 
sides, there is always the chance that the case may be one of those which 



198 EXTRA-UTERINE PREGNANCY. 

have been described as suh-peritoneo-pelvic. The operation, if resolved 
upon, consists in an incision through the vaginal walls, and the removal, 
by forceps or otherwise, of the foetus. 

If the pregnancy has reached the eighth month, and the life of the 
foetus is indicated by the usual signs ; and, if the sac can be reached only 
through the abdominal walls, it is, of course, possible to anticipate rup- 
ture, and to extract, by gastrotomy and incision of the sac, a living foetus. 
In the performance of this operation few obstacles or difficulties would 
seem to arise. But, if we balance the hope of the child's life against 
what is almost the certainty of the mother's death — there are, perhaps, 
few contingencies in surgical or obstetrical practice in regard to which 
the sense of responsibility will be more keenly felt. It is so far satis- 
factory to know, that recent experience has dispelled what was at one 
time believed to be the chief difficulty on the maternal side — viz., the 
removal of the placenta ; and, indeed, it is now universally admitted that, 
if we perform the operation at all, we only augment the danger to the 
mother by any attempt to detach the placenta from the site to which it is 
adherent. There are cases in which this operation may be the only 
chance for the mother's life, and we are certainly entitled to hope that 
the great success which has of late years followed the operation of anti- 
septic ovariotomy may point to the possible saving of lives which have 
hitherto been yielded up as hopeless. And, perhaps, a day may come 
when diagnostic skill being more certain, an early extra-uterine foetation 
may be removed and ligatured with as great a prospect of success as an 
ovarian cyst. In cases where a living mature child has escaped by rup- 
ture of the sac into the abdominal cavity, we need have no difficulty, for 
here the analogy is complete between the case in question and one in 
which a living child has similarly escaped through a uterine rupture ; 
and, by the operation in these circumstances, the risk to the mother will 
be little aggravated, while the life of the child may possibly be saved. 

In the case of a woman who has carried, for one or more years, an 
extra-uterine foetus, which causes her great suffering, or which is obvi- 
ously undermining her general health, the question of operation may 
also suggest itself, although in a dififerent form. The rule which must 
here guide us is, in addition to the state of her health, the possibility 
of reaching the tumor from the vagina ; for, unless we were convinced 
of the existence of adhesions to the anterior or lateral abdominal 
walls, an operation in this direction would, we conceive, seldom be 
warranted. 

The duty of the surgeon will, however, in most cases, be confined to 
carefully watching and cautiously assisting in the separation of the 
foetal debris. Should one or more fistulous openings exist in the 
abdominal walls, the vagina, the perineum, or the rectum, the nature 
and extent of the cavity of the sac may be carefully explored through 
them. By the aid of sponge-tents, the apertures may be safely dis- 
tended, and any loose portion removed ; care being always taken not to 
drag rudely such fragments as may be adherent to the walls of the sac, 
as, by doing so, the sac might be ruptured, and peritonitis ensue. If 
the communication has taken place in the direction of the bladder, it 
may be necessary to remove them by one of the operations for lithotomy, 



ABNORMAL DEVELOPMENT. 199 

or by dilatation of the urethra, as was done by Professor G. H. B. 
M'Leod in a case which he communicated, many years ago, to the 
Medico-Chirurgical Society of Glasgow. While the separation of the 
remains of the foetus is thus promoted, in any way which experience 
may suggest to us as consistent with safety, the general health of the 
woman must be carefully attended to, her strength being sustained by 
nourishing food and suitable stimulants, while any tendency to hectic or 
irritative fever must receive its appropriate treatment. 



CHAPTEE XII. 

ABNORMAL DEVELOPMENT. 

Molar Pregnancy. — False Moles: from Vagina: Membranous Dysmenorrhoea: 
Fibrinous and Hemorrliagic Casts of Uterus. — True Moles: Fleshy Moles: 
Hydatidiform Moles ; Their Pathology, Diagnosis and Treatment. — Diseases 
of the Placenta, and their Effects. — Missed Labor. — Diseases of the Foetus. — 
Intra-uterine Fractures and Amputations : Efforts at Reproduction. — Monsters. 

There are, in addition to the peculiarities of development already 
noticed, certain others which deserve special mention in a systematic 
treatise, but are not unfrequently passed over as of no moment. There 
is every reason to suppose that these peculiarities have their origin, in a 
large proportion of instances, in actual disease of the ovum ; but, whether 
this is, or is not, the primary cause of the affections in question, no 
doubt can, in the present state of pathological knowledge, be admitted, 
as to the frequent coincidence of disease or degeneration of the ovum, 
either with arrest of development, or with the transference of develop- 
mental energy to structures which are merely subsidiary. The result of 
this is the occasional expulsion from the uterus of substances, the nature 
of which it is not always easy to determine, and the origin and pathology 
of which have often been misunderstood. These substances are generally 
termed Moles. 

It must be made clear, however, from the outset, that all solid matters 
discharged from the uterus are not moles, properly so called. In other 
words, all such discharges are not the result of impregnation, — a fact 
which is of obvious medico-legal importance, and imposes upon us the 
necessity of drawing a careful distinction between " true''' and ^\false^^ 
moles. The matters which are discharged from the virgin, or which are 
independent of impregnation, and which might be mistaken for the result 
of conception, form but few varieties, and constitute what are termed, 
w^ith questionable propriety. False Moles. Under this designation may 
be included bodies, which are composed mainly of the squamous epithe- 
lium of the vagina, thrown off in the form of flakes, or tubular casts ; 



200 ABNORMAL DEVELOPMENT. 

and which may either be expelled singly, or form, by their union, masses 
of greater or less bulk, but seldom of any considerable size. A careful 
examination of these by the microscope, or even by the eye, will gene- 
rally obviate the possibility of error ; but, as regards the following, the 
unwary may easily be misled. 

It is a fact familiar to every physician, that the most obstinate and 
intractable form of painful menstruation, or dysmenorrhoea, is the mem- 
branous variety, in which the mucous membrane of the uterus is shed at 
each catamenial period, either in shreds of various size, or in the form of 
a single mass, forming a complete cast of the uterine cavity. There 
seems good reason to believe that, in the majority of such instances, — 
more particularly as they occur most frequently in the married state — 
impregnation is a factor in the case ; but it is equally certain that in 
other instances there is a shedding of the membrane independent of preg- 
nancy. Obviously, therefore, great caution must be exercised in admit- 
ting a presumption of pregnancy ; but we may be guided in some degree 
to a correct conclusion by the presence or absence of the early signs of 
pregnancy. Still, it is not too much to say that we can never be justi- 
fied in assuming that pregnancy has existed unless we can make out the 
villi of the chorion, or something equally characteristic of embryonic 
structure. When unconnected with pregnancy, moreover, there is no- 
thing corresponding to the decidua reflexa, even although the structure, 
when disoharged, presents three openings, — one for each Eallopian tube, 
and one at the point of connection with the cervix uteri. 

A third variety of false mole has been described as occurring under 
certain conditions of functional derangement of the uterus, more espe- 
cially when this is accompanied with some form of inflammatory action. 
In it, the substances expelled are of a fibrinous appearance externally, of 
a firm consistence, and varying greatly in size, but frequently presenting 
the form of a cast of the uterine cavity. Most frequently these are com- 
posed of blood-clots, which have become condensed and altered in appear- 
ance by their decolorization externally. In certain cases, they appear 
to be composed partly of clot and partly of lymph ; while in others, 
which have been carefully observed, it would appear that a membranous 
cast has been surrounded by an outer layer of condensed coagulation.^ 

The True Moles differ from the above essentially in this, that they are 
in every instance the result of conception, in which, generally, the em- 
bryo has been blighted, and yet development of the membranes has pro- 
gressed with abnormal activity. In the investigation of these cases, it is 
of importance to remember what Smelhe tells us. " Should the embryo 
die," he says, " (suppose in the first or second month) some days before 
the ovum is discharged, it will sometimes be entirely dissolved, so that 
when the secundines are delivered there is nothing more to be seen. In 
the first month, the embryo is so small and tender that the dissolution 
will be performed in twelve hours ; in the second month, two, three, or 
four days will suffice for this purpose." If this is the case when the 
ovum is expelled shortly after the death of the embryo, it need not 

* Tliese formations are fully described and admirably depicted by Dr. A. B. Gran- 
ville, in liis admirable monograph on Abortion and the Diseases of Menstruation. 
London, 1833. 



TRUE MOLES. 201 

astonish us that when it is retained for a considerable period all trace of 
embryo has disappeared, while the membranes are so degenerated or 
metamorphosed that it is only with difficulty that the true nature of the 
case can be recognized. 

Of the highest interest and importance in reference to this subject, 
and more especially to the .question of etiology, are the hemorrhagic dis- 
charges of which the ovum is the seat. In addition to the direct effect, 
which must spring from the sudden abstraction of blood either from the 
foetal or maternal vessels connected with the ovum, the blood which Hows 
from the ruptured vessels very frequently exercises a mechanical influ- 
ence in the separation of contiguous parts, with the most disastrous 
results. Blood may thus be interposed by the rupture of the utero- 
decidual vessels, and so cut off the only maternal supply possible lor the 
early embryo. Or, at a later stage, hemorrhage from the utero-placental 
vessels may so engorge the parenchyma of the placenta, as to cause 
apoplexy of that organ, an affection which Ave shall have occasion here- 
after to mention. Again, the extravasation may take place between the 
chorion and the decidua reflexa, or even within the amnion, destroying 
the embryo and giving rise to abortion. Particular attention has been 
given by Scanzoni to the various forms of apoplexy of the ovum, a sub- 
ject which is of interest to us at this stage, as a cause not only of death 
of the embryo, and of abortion, but also of the formation of true moles, 
when abortion does not at once ensue. His conclusions as to the progress 
and termination of the hemorrhage are as follows: — 

'' 1. If the -flow of blood is simply from the utero-placental or utero- 
decidual vessels, and the quantity is inconsiderable, this does not suffice 
to separate the ovum in the greater part of its circumference, or by 
mechanical pressure to arrest its further development ; so that blood 
effused between the uterine walls and the decidua, or even between the 
two layers of the latter, may be either completely or, at least, partially 
reabsorbed, and the pregnancy may reach its normal termination. 

" 2. But if the quantity of the effused blood is considerable, the ovum 
is separated from the uterine walls either entirely or to a great extent, 
and is compressed by the voluminous coagulum, and more or less flat- 
tened : such compression actually causes bursting of the membranes (of 
which Dubois narrates a case), when abortion is the usual result. 

"3. The same is the result when the foetus dies through rapture of 
its own vessels and the placental hemorrhage thus induced. Here also 
the abortive ovum is expelled, the rapidity with which the abortion 
occurs depending especially on the occurrence of simultaneous uterine 
hemorrhage. 

" 4. If the ovum, as is much more rarely the case, remain with the 
dead foetus for a considerable time in the uterine cavity ; the coagulum 
undergoes certain changes, which are also observable in extravasation in 
other parts of the body, and so gives occasion for the origin of the forma- 
tion known under the name of Fleshmole." 

The Fleshy Mole (Mola Carnosa) is pfobably formed in part from 
coagula and in part from the membranes of the ovum, which undergo 
a species of degeneration by some such series of changes as the follow- 
ing : The effused blood becomes in the first instance decolorized by 



202 ABNORMAL DEVELOPMENT. 

rupture of the blood-corpuscles and absorption of their coloring matter. 
This decoloration takes place from the centre towards the circumference. 
The j&brine, as Scanzoni supposes, becomes transformed into cellular 
tissue, by means of which communication is established between the 
external lining of the ovum on the one hand, and the inner surface of 
the uterine wall on the other, — so that the .further development of the 
structures thus in apposition is rendered possible. We may assume that 
in these cases complete separation of the ovum cannot have taken place, 
otherwise the death of the w^hole structures of the ovum would have 
rendered its expulsion inevitable. And, as the connection between the 
uterus and the ovum is most firm at that part where the placenta has 
either formed or is about to form, the probability is that the vascular 
supply sent to the ovum through this channel is never entirely cut off. 
On the establishment of new and more extensive adhesions, the blood- 
supply is at once augmented, and the membranes and effused coagula 
become intimately bound together into a mass, through which vessels 
freely run, and which becomes hypertrophied to a very considerable 
extent. It would appear that, at least under certain circumstances, the 
chief seat of the carneous degeneration is the decidua vera ; for it is 
certain that, in many of the cases which have been most carefully exam- 
ined, the structure of the chorion has been distinctly recognized by its 
villi, although the membrane itself has undergone some considerable 
thickening. The villi in these cases have been found to consist of mole- 
cular masses and fat cells. The amnion undergoes little change, and 
may be found adhering to the inner surface of the chorion, and contain- 
ing within its cavity a certain quantity of bloody fluid, in which will be 
found what remains of the embryo. The rudiments of the embryo are, 
however, frequently very indistinct, unless the pregnancy should chance 
to have been more advanced than usual ; and, indeed, difficulty will 
frequently be experienced in tracing even the remains of the cord, 
although the chorion and amnion may be tolerably distinct. The nature 
of the case will nevertheless usually be recognized, on a careful exami- 
nation, by the discovery of the villi of the chorion ; and Scanzoni asserts 
further that, in the cases examined by him, he has never failed to dis- 
cover the enlarged villi by the cgency of which the placenta was already 
going through the earliest stage of its formation. While in all these 
cases the diseased membranes go on increasing in bulk, they are, of 
course, rendered quite unfit for the discharge of their primary functions, 
so that the contained embryo, if its death has not preceded the degene- 
ration, must speedily succumb. " When the growth of the ovum," says 
Rigby, " proceeds after the destruction of the embryo, it increases very 
rapidly in size, much more so than would be the case in regular preg- 
nancy, so that the uterus, when filled with a mole of this sort, is as 
large at the third month as it would be in pregnancy at the fifth." As 
the development of the mole goes on, it increases in density as well as 
bulk, and the growth may continue for three or four months, until its 
presence within the uterus a\^akens expulsive efforts, when it is speedily 
expelled, presenting the characteristics just detailed. 

Cases occasionally occur in which fatty degeneration is the most con- 
spicuous characteristic of a mole ; but this we may merely mention as a 



HYDATIDIFORM MOLES. 



203 



variety of the fleshy form ; and the same remark may be made in regard 
to what has been described by German authors as the '^Steinmole^'''' a 
variety which seems to attend a retention of the mole within the uterus 
for an unusually long period ; and which implies, as its name indicates, 
a calcareous degeneration of what had been originally an ordinary fleshy 
raole. With reference to sxich cases, it may, however, be remarked that 
such calcareous masses are to be cautiously received as evidence of mole 
pregnancy, unless the characteristics of the latter are clearly manifested. 
For we know that fibroid tumors of the uterus are also subject, although 
rarely, to a similar degeneration ; and it is quite within the bounds of 
possibility that an error of some magnitude might here be committed, 
seeing that these concretions are sometimes spontaneously separated from 
the uterus, and discharsjed through the vagina. 

The Hyclatidiform 3IoIe. — The bodies which form the distinguishing 
feature of these moles w^ere long supposed to be true hydatids, formed 
in and discharged from the uterus. More 
careful examination showed, however, that Fig- 95. 

they were not, like true hydatids, closed ,^,., -//y^J^'^ ] 

sacs within one another, but that the vesi- 
cles were arranged in a manner quite diff"er- 
ent from this, each saccule growing from 
another, in regard to which it is either ses- 
sile, or connected by a pedicle of varvins: 



) 



length. 



In this manner, cyst grows out of 



cyst, and the pedicles do not unite them 
with principal stems, but w^ith each other, 
so that, as Mettenheimer and Barnes have 
shown, it is incorrect to compare them, with 
Gooch, to currants, or, with Cruveilhier, to 
a bunch of grapes. The arrangement is 
very well shown in the annexed representa- 
tion of a mass of these bodies which had 
been expelled from the uterus. The vesi- 
cles vary considerably in size, from a walnut 
downwards, according to the development 
which they have attained, or the distance 
at which they are situated from the parent 
cyst, from which they originally spring. 
Not unfrequently, when they escape unex- 
pectedly, they are brought under the notice of the practitioner floating 
in a basin of w^ater, and discolored with blood ; and under these circum- 
stances the graphic description of Gooch is singularly applicable, for 
they then resemble very closely a mass of " white currants floating in 
red currant juice." 

Although the exact mode in which the vesicles constituting the hyda- 
tidiform mole are formed is not yet clearly fixed to the satisfaction of 
all, there is one point in which all modern authorities are agreed, viz., 
that they spring from the villi of the chorion. It is also admitted that 
in this, as in the fleshy raole, we have no new formation, but simply an 
alteration and degeneration of previously existing structures. But when 




Hydatidiform Degeueration of Ovum. 



204 ABNORMAL DEVELOPMENT. 

Ave come to consider the pathological process by which this alteration is 
effected, we find that considerable differences of opinion exist. The 
views on this subject originally propounded by Mettenheimer in 1850, 
in '' Miiller's Archiv," and which have been indorsed in this country 
by Paget and Barnes, are those which are generally entertained. The 
villi of the chorion, as has been pointed out by modern physiologists, 
grow normally by a process of gemmation, bud springing from bud in 
successive stages of growth. Under the influence of perverted develop- 
ment, these buds, or the elementary cells of which each villus is com- 
posed, take on a new action, and become transformed into vesicles, which 
vary in size, and to which attaches the power of repeating the process 
of chorion development, still in a perverted sense, until the so-called 
hydatidiform mass is formed. Gierse is of opinion that the change con- 
sists in hypertrophy of the normal structures found in the chorion villi, 
with secondary oedema ; and Dr. Graily Hewitt urges that the vesicular 
transformation is a consequence, and not a cause of the death of the 
embryo, and that it is therefore nothing more than a degeneration of 
structures arrested in their development. We fail to see, however, that 
the death of the embryo, prior to the formation of the cysts, is in any 
way incompatible with the theory of Mettenheimer ; indeed, we cannot 
but think it extremely probable that in this, as in the case of fleshy 
moles, it is the developmental force diverted by the death of the embryo 
into an unwonted channel which is the great cause of the activity of the 
degenerative process. And, moreover, this is all the more likely to take 
the form of cystic degeneration on account of the peculiar anatomical 
conditions under which the villi of the chorion, and more especially those 
of the placenta, are produced. The period within w^hich hydatidiform 
degeneration may originate does not probably extend beyond the tenth 
week, for it is during that period that the activity is greatest in the 
growth and multiplication of the villi ; and, at a later stage, when blood- 
vessels have largely occupied the bulk of the villi, it would appear that 
they are no longer capable of undergoing that form of degeneration. A 
certain dropsical condition, or secondary oedema, as Gierse describes it, 
of the membranes, is probably an essential part of the degeneration in 
question, and may serve to account for the constant supply of the fluid 
which fills the sacs. Although the special activity in the development 
of the villi, which ultimately would have formed the perfect placenta, 
might naturally be expected to attract thither the morbid action, experi- 
ence has shown that this is not invariably the case. An important ques- 
tion has arisen as to whether a portion of placenta, retained at the full 
term, can take on hydatidiform change. This has been answered in the 
affirmative — among others, by Montgomery and Ramsbotham — but all 
recent writers dispute the conclusion. 

In the majority of cases, an examination conducted with every care 
shortly after expulsion fails to detect any trace whatever of the embryo, 
although in some instances a foetus has been discovered, and this is, 
doubtless, what has led to the erroneous conclusion referred to. The 
explanation of the facts as observed is to be found in the fact, that here, 
growth is limited to the chorion and the degenerated villi, and that the 
uterus is filled with an enormous mass of cysts which have sprung from 



THE HYDATIDIFORM MOLE. 205 

this source, so that the cavity of the amnion and its contents are almost 
inevitably obliterated. The destruction of the embryo is, for this reason, 
much more complete than in the fleshy variety of mole. 

In regard to the symptoms of this form of mole, they are at first 
identical with the ordinary signs which are supposed, in the first three 
months, to indicate pregnancy. The usual symptoms, and more espe- 
cially those which have their seat in the mammiie, then become indistinct 
and perplexing. The patient is ill at ease, her appetite and digestion 
become impaired, and her feelings are quite different to those which 
attended former pregnancies. So soon as the degenerative process has 
been thoroughly established, the increase in the bulk of the uterus goes 
on with very unusual rapidity, and it has been noticed to expand irregu- 
larly, and more in a lateral than in the usual upward direction. When 
the period arrives at which the conclusive proofs of pregnancy should, 
under ordinary circumstances, be distinctly manifested, the absence of 
foetal pulsation and ballottement may arouse suspicion as to the nature 
of the case. But, at a period even earlier than this, watery and san- 
guineous discharges, mixed or separately, may occur, the former being 
due to the distended vesicles, which have probably been submitted to 
considerable pressure. It occasionally happens that, along with these 
discharges, a few vesicles only, or a larger proportion of the mass, 
escape, which at once reveals the nature of the case. There is, in 
addition, another symptom to which we would call special attention, 
and which we have found of the highest importance in practice in the 
diagnosis of this affection. This consists in a peculiar doughy, boggy 
feeling, which is revealed on palpation, and w^hich we take to be in the 
highest degree characteristic, more especially if we take along with it 
the absence of that irregular hardness which indicates the prominences 
of the foetus. The term " dense" which we find generally used to de- 
scribe the feeling of the uterus in this condition is, although applicable 
to some cases, as a rule, inappropriate. " Tense," again, would repre- 
sent correctly enough the effect of the rapid distension ; but the sensa- 
tion yielded by palpation, which we have had the opportunity of tho- 
roughly testing in several cases, is, we are persuaded, more correctly 
described above, than by either of the terms specified. 

The existence of moles of this nature is seldom prolonged beyond the 
sixth month, when repeated hemorrhage, and over-distension of the uterus, 
entailing probably a partial separation of the placenta, will usually have 
excited uterine contraction. The effect of these contractions, when once 
thoroughly aroused, is to effect the complete separation of the entire 
ovum, which insures the safety of the woman by the arrest of the hemor- 
rhage. It would seem, however, that under certain special circumstances, 
fortunately of rare occurrence, the connection between the uterus and 
the ovum is so firm that a portion only of the fruit of conception is ex- 
pelled. " In such cases," says Scanzoni, " portions of the ovum remain 
behind in the uterine cavity for a considerable time, on account of their 
firmer connection with the inner wall of the uterus. These may give 
rise to profuse and long continued floodings, as we have seen in one of 
our cases occurring in the gynaecological clinique at Prague, where an 
exhausting hemorrhage, which had continued for some months after the 



206 ABNORMAL DEVELOPMENT. 

expulsion of a vesicular mole, was first arrested on the removal by the 
hand of the remainder of the ovum, which had remained behind in the 
cavity of the uterus." 

What is, however, of more frequent occurrence when the whole of the 
ovum is not at once expelled, is that the case turns out to be one of twin 
pregnancy, in which the membranes of one embryo only have become the 
seat of the degeneration in question. Generally, under such circum- 
stances, the uterus, after expelling a large hydatidiform mass, will not 
cease in its efforts until the whole of its contents have been expelled, but 
a certain number of cases have been recorded, in which, after such an 
event, a fully developed child has been expelled after an interval of a 
few months, a fact which is only reconcilable with the idea above ex- 
pressed. This is said by Montgomery to have occurred at the birth of 
the celebrated anatomist Eeclard. The most recent observations on this 
subject seem to indicate that examples of this nature are by no means 
of unfrequent occurrence, which obviously shows that we should exercise 
caution in the treatment of such cases, lest we destroy the living germ 
while removing the dead. 

The treatment of all such cases will of course depend on the urgency 
of the symptoms. So long as they are moderate in severity, and are not 
such as to call for immediate action, our course of treatment must be 
purely expectant, more especially as there will almost always be an ele- 
ment of doubt in the diagnosis. But, so soon as profuse watery and 
hemorrhagic discharges indicate serious danger to the woman, we must 
not delay until interference is a mere dernier ressort, but act promptly, 
and in the manner most likely to empty the uterus speedily of its con- 
tents. In several cases of hydatids, we have found the ergot of rye act 
quite satisfactorily, and effect expulsion without difficulty : as, indeed, it 
usually does when the uterus has reached a certain degree of distension. 
We recommend, therefore, that in the first instance, this drug should be 
employed ; but if, as often happens, it fails to excite uterine effort, we 
must then resort to other means. A sound or catheter has been introduced 
into the womb, and successfully used so as to break up the mass, and 
separate it as far as possible from its uterine attachments ; but we regard 
it a safer as well as a more satisfactory method, to dilate the os and cer- 
vix by means of Barnes' bags or other similar appliances, so as to intro- 
duce the hand, and remove at once the whole mass. The dilatation of 
the OS and cervix by means of sponge tents Avould also have the effect of 
exciting the uterus to contraction, and would have the further advantage 
of checking hemorrhage. Galvanism has also been recommended; the 
object, of course, in each and all these modes of procedure, being to 
empty the uterus safely as well as quickly. Nothing special need be 
said in reference to the treatment of the fleshy mole, as in that case the 
diagnosis is much more difficult. Although the unexpected arrest of 
development, and the general constitutional disturbance, with the cessa- 
tion of such of the signs of pregnancy as may previously have been pre- 
sent, may indicate the probability of this affection, it is seldom that its 
nature is recognized until the carneous mass, with the blighted ovum, 
has been expelled. 

There is yet another group of cases in which the pathological pheno- 



DISEASES OF THE PLACENTA. 207 

mena are also to be found in a portion of the ovum, but which occur at a 
later period of pregnancy than those which we have just been consider- 
ing. In these instances, development goes on uninterruptedly until the 
placenta has been fully formed ; and it is to diseases of that organ that 
the death of the foetus is then due. Among the aifections of the pla- 
centa which may have this result, is Apoplexy of the Placenta, in which 
blood is effused, by rupture of vessels, into the parenchyma of the organ, 
exactly as takes place in the lung, and with a similar result as regards 
the respiratory function. Another aifection which, as we have already 
seen, is apt to attack the tissue of the fleshy mole, is Fatty Degeneration. 
Recent researches show that, at a more advanced period of gestation, 
the same pathological change is apt to invade the tissue of the placenta, 
and so to alter its structure as to interfere seriously with, and ultimately 
to arrest, the development of the embryo. The cause of this fatty de- 
generation has been very carefully investigated by Barnes, Priestley, 
and others ; and the conclusion at which they seem to have arrived is, 
that the fatty molecules are the result of a low form of placentitis, — 
being either thrown out, primarily, as inflammatory exudations, or 
formed, secondarily, of inflammatory products wdiich subsequently de- 
generate into fat particles. Placentitis is another affection which may 
cause intra-uterine death, — the inflammatory process, in these instances, 
attacking the organ, and in extreme cases leading to hepatization, indu- 
ration, abscess, and the other terminations of the inflammatory state. 
The morbid action is generally confined to a limited portion of the organ, 
or to a few lobules, and extends from the maternal towards the foetal 
surface of the placenta. There is reason to believe that morbid adhesion 
of the placenta may have its origin in placentitis ; and, in connection 
with it, hypertrophy of the decidua serotina has not unfrequentlv been 
observed. General oeiema, or dropsy of the placenta, is another aff'ec- 
tion of the organ which has been carefully observed by Meckel and 
Gierse. The appearances are here altered to those which are charac- 
teristic of oedema in all soft tissues, — swelling, paleness in color, and 
serous infiltration, being the leading features which an examination of 
the tissue reveals. " This must not," as Simpson well remarks, " be 
confounded with the wdiite, blanched, and merely anaemic state of the 
placenta, often observable in cases where the child has died of peritonitis, 
or other foetal diseases, and been retained in utero for some time subse- 
quently ; and it is pathologically very diff"erent also from the stearoid or 
fatty degeneration." 

Hypertrophy of the placenta, cartilaginous and calcareous degenera- 
tion, ramollissement, and atrophy are all aS'ections which have been 
specially observed. In many of the affections above enumerated, there 
seems to be a tendency to return in subsequent pregnancies ; and it may 
be held as an established fact that such has been the case in many of 
those instances of repeated abortion which cause so much disappointment 
to the mother. Under the influence of these degenerations, the nutrition 
of the placenta may, for a time, go on uninterruptedly. Soon, however, 
its function is interfered with, and the safety of the foetus becomes com- 
promised. The general rule, in such circumstances, undoubtedly is, that 
the uterus is excited by the foreign body to active contraction, and abor- 



208 ABNORMAL DEVELOPMENT. 

tion is the result. But, in a certain number of instances, the diseased 
vitality of the placenta is maintained, while the embryo becomes shrivelled 
and attenuated to an extraordinary degree, — under which conditions it 
may be retained until the full term of gestation is reached, and then dis- 
charged. This latter result is more likely to occur in twin than in single 
pregnancies, — the placenta of the one foetus being diseased, and the other 
remaining healthy ; and it is probably under such circumstances that, 
with a fully formed child, a shrunken foetus is sometimes expelled — 
giving rise, erroneously, to the idea of superfoetation. The dead foetus, 
in these instances, is generally flattened by the pressure which is exer- 
cised upon it by the other in the course of its development. 

An extremely rare and curious phenomenon has been occasionally 
observed, in which, the foetus remaining in utero, labor does not come 
on at the usual time ; and the remains of the foetus may be retained for 
a considerable period, or discharged piecemeal by the vagina, without, 
for a time at least, seriously affecting the health of the mother. This 
has been called Missed Labo7\ and is alluded to by Dr. Tyler Smith in 
his admirable Manual, in which he gives the history and illustration of a 
case which occurred in the experience of Dr. Oldham. 

The Umbilical Cord may also, like the placenta, be the seat of certain 
anomalies, or morbid affections, which may cause the untimely death of 
the foetus. Under the former class may be ranged cases of true knots 
on the cord, and twisting of it round various parts of the child, which 
may possibly be attended with fatal results ; and, under the latter, may 
be mentioned inflammation of the cord, or of any of its parts, and 
cystic degeneration, which was first described by Ruysch, and has been 
mentioned by subsequent writers, although it is probably of very rare 
occurrence. 

Diseases of the Foetus. — Having now considered the cliief morbid con- 
ditions which affect the various parts of the ovum, including the placenta, 
we may at this place advert, with propriety, to certain diseases to which 
the foetus itself is liable. With few exceptions, the foetus may be said 
to be subject to the same diseases as are observed after birth. Among 
the most frequent are the aff"ections of the nervous centres which are due 
to hemorrhages ; or which consist primarily in inflammatory aff'ections, 
from which spring secondary eff'ects, attended with very serious results 
to the mother as well as to the child. Hemorrhages into the substance 
of the foetal brain are very rare ; but it is not so much so in regard to 
discharges which take place behind the membranes or on the surface of 
the brain. These affections when observed, and when unconnected with 
obstructed delivery, have usually been found associated with placental 
apoplexy or obstruction of the cord. Of all the results of inflammatory 
action in this situation, the most familiar is chronic hydrocephalus, in 
which the quantity of serum effused within the cranium is often so great 
as not only to cause a certain amount of atrophy of the encephalon, but 
also an increase in the size of the head, so considerable as to form a 
serious obstacle to delivery. Convulsions may attack the foetus while it 
is yet in the womb, and cases have been observed in which convulsions 
on the part of the mother were communicated to the child. The probable 
cause of these, in most instances, is arrest of the circulation, which 



DISEASES OF THE F(ETUS. 209 

causes the foetus to die of apncea, — of which convulsive action is a fre- 
quent symptom. Although the lungs are as yet of very small size, it 
would appear that they are occasionally, though very rarely, the seat of 
inflammation ; but pleurisy and tuberculosis are of much more frequent 
occurrence than pneumonia. Acute and chronic peritonitis, whether 
general or partial in extent, is met with much oftener thaii the above. 
This affection may be accompanied with effusions, which are identical in 
appearance and general characteristics with those which are so frequently 
observed after birth ; and, according to the type of the inflammatory 
action, they may take the form, either of coagulable lymph, by means of 
which the viscera may be glued together, or of a fluid effusion, the quan- 
tity of which may become enormous, and may cause the death of the 
foetus either before or after birth, or may even render delivery difficult. 
It would appear from certain researches made by Simpson in reference 
to this affection, that it is not unfrequently associated with syphilitic 
disease of the mother. Diseases of the liver and of the spleen, many of 
them associated with the same constitutional disorder, have also been 
frequently observed ; and, more rarely, affections of the alimentary 
canal, with which may be classed cases of Ascarides and TjTenia, these 
entozoa having been repeatedly found in the intestines of the unborn. 
Congestion, hydronephrosis, cystic degeneration, and other affections of 
the kidney, as well as various affections of the ureter, have occasionally 
been noticed ; and the same may be said with reference to cardiac dis- 
eases, examples of which, including peri- and endo-carditis, have also 
been noted. Various diseases of the skin are observed in children born 
either prematurely or at the full time, including the characteristic erup- 
tion of certain febrile diseases, such as variola, which may be contracted 
from the mother within the uterus ; or, what is much more wonderful, 
which may be communicated through the mother to the child, she herself 
remaining unaffected. Erythema, pemphigus, and other forms of skin 
disease, are very frequently to be received as evidence of the existence 
of syphilitic disease, in one parent or in both. 

Fracture of the bones of the foetus is an affection which is usually the 
result of violence from without ; but a sufficient number of cases have 
been observed to establish the fact that, independently of any such acci- 
dent, intra-uterine fracture may occur. Some of the recorded instances 
of this are of the most extraordinary nature. Chaussier, for example, 
tells us of one case in which there were forty-three, and another in which 
there were no fewer than one hundred and thirteen fractures of the bones 
of the foetus, facts which it is difficult to understand, unless under the 
supposition that extensive disease of the bones existed. 

But a more extraordinary phenomenon still is the occurrence within the 
womb of what has been described as spontaneous amputation. Haller, 
and many physiologists after him, supposed that these were cases of simple 
arrested development, but that this cannot be the case in every instance 
is proved by the discovery within the uterus of the missing part. The 
fact of this spontaneous amputation having, at a more advanced period, 
been clearly established by irrefragable evidence, the question which next 
presented itself for solution was the manner in which such a separation 
within the uterus could by any possibility take place. To this, the reply 
14 



210 ABNORMAL DEVELOPMENT. 

given by Chaussier, Billard, and other writers of that period, was that 
the only manner in which it could be accounted for was to suppose that 
the parts separated had been the seat of gangrene, and that spontaneous 
amputation had taken place at the line of demarcation between the living 
and dead tissue. The discovery in several cases of -the amputated part, 
which had' not undergone any decomposition, soon proved that this theory 
was quite erroneous, and it is to Montgomery that we owe what is now 
generally believed to be the correct explanation of what was long a patho- 
logical problem. Montgomery's view, which has, since he wrote, received 
the most ample confirmation, was that the intra-uterine section was efiected, 
either by constriction exercised by the cord, or by special bands consisting 
originally of organized lymph, such as is usually elaborated under the 
influence of inflammatory action. These bands or threads having become 
fixed round a limb, their compressive power becomes daily augmented, on 
the one hand, by their own contractions, and, on the other, by the growth 
of the body within their grasp. In the majority of cases, the complete 
separation of the limb is not effected, and it is only partially divided. 
But, if the processes of contraction and growth continue, the supply of 
blood to the distal part of the limb is first diminished and then cut off; 
and, ultimately, the nutrition of the bone being similarly interfered with, 
it becomes brittle, and probably breaks ofi' short at the point of constric- 
tion. A most interesting observation, which we owe to Simpson, in con- 
nection with this subject, is the occurrence in these instances of an 
ailtempt on the part of nature to remedy the deficiency by a process of 
reproduction which is familiarly low in the animal scale, but of which, as 
we ascend, nature avails herself less and less. When, in a case of this 
kind, as he shows by reference to a considerable number of cases, sepa- 
ration in utero occurs, a stump is found which offers certain peculiarities 
in appearance. "Two points of the skin, or rather of the subcutaneous 
tissue, are found adherent to the end of the ulna and radius, and present 
a depressed or umbilicated form, particularly when the forearm is flexed 
and moved, and the fissures of the skin run in converging lines to these 
two points as centres. Midway, and a little in front of these two points, 
the rudiment of the regenerated extremity is situated in the form of a 
raised cutaneous fold, or fleshy mass, or tubercle, and having on its sur- 
face one, two, or more smaller pro- 
»• jections or nodules, furnished with 

minute nails." In illustration of 
this, the appended engraving is 
given, representing the stump of 
the left^ forearm of a foetus of the 
seventh month, preserved in the 
Obstetric Museum of the Univer- 
sity of Edinburgh. There are five 
small rudimentary fingers tipped 
with minute nails, in the usual po- 
sition on the end of the stump. 
, . Deviations from the ordinary 

Intra-uterine Amputation and attempted c ■> ^ o L^ 

Reproduction. proccss 01 development frequently 

It is somewhat remarkable that this accident generally occurs on the left side. 




DISEASES OF PREGNANCY. 211 

give rise to results ^vhich constitute Monstrosities. The subject of mon- 
sters, however, although it might fairly enough be discussed here, 
is one of such magnitude that we must needs pass it by, as it is quite 
impossible to give to it even the briefest notice in a work such as this. 
Those who would pursue the subject may refer to the magnificent 
Traite cle Teratologie by Geoffroy St. Hillaire,and to other works where 
the subject is fully and exhaustively treated. The Anencephalic, Cyclo- 
cephalic, and other varieties which consist in the absence of portions of 
the cranium and subjacent parts, are interesting chiefly, from a purely 
practical point of view, as being likely to puzzle any one who, on making 
a digital examination during labor, might chance to touch such a forma- 
tion. Double monsters are, as we shall see, interesting in their practical 
bearing, as being certain to be attended with difficult labor, but, as a 
whole, the subject of monstrosities and malformations is here quite beyond 
our grasp. 



CHAPTEE XIII. 

DISEASES OF PREGNANCY. 

I. Disorders of the Digestive Functions. — Excessive vomiting : treatment of : 
question of Induction of Premature Labor in. — Anorexia — Gastrodynia — Pyro- 
sis — Constipation — Diarrhcea. — II. Disorders ©"f Respiration. — Dyspnoea 
— Cough. — III. Disorders of the Circulation. — Condition of the Blood in 
Pregnancy : diminution of Red Corpuscles : proportional alteration in Fihrine 
and Albumen. — Supposed resemblance of the Phenomena of Pregnancy to those 
of Chlorosis. — Administration of Iron in Pregnancy. — Plethora. — Varicose 
Veins. — Hemorrhoids. — Thrombus of the Vagina. 

Many of the symptoms which have already been detailed as indicative 
of pregnancy are such as, under ordinary circumstances, would be re- 
garded as pathological phenomena, and would be classed as Diseases or 
at least as Disorders. But, under the special circumstances attending 
the pregnant state, which implies the development of a function purely 
physiological, these symptoms, which are in a great measure the result 
of sympathetic or reflex irritation, are naturally looked upon as physio- 
logical indications of a natural process. So long, at least, as they are 
confined within moderate limits, it is usual either to treat them by means 
of mild palliative measures, or to disregard them altogether, provided the 
general health does not seem to be in any serious degree affected. A 
very small amount of practical experience suffices to show that great dif- 
ferences exist, consistently with a perfectly healthy pregnancy, in the 
gravity of the symptoms which are manifested ; a Avoman, in one case, 
being scarcely exposed, during the whole period of her pregnancy, even 
to discomfort ; while, in another, with an equally happy result, disagree- 



212 DISEASES OF PREGNANCY. 

able symptoms of one kind or another have been well-nigh incessant. 
The difficulty, therefore, is where to draw the line, and to determine what 
cases demand treatment, and in what others interference is to be avoided. 
These remarks apply especially to the abnormal digestive phenomena 
which so invariably attend pregnancy, and to certain other symptoms 
which may be referred to the same category. There are, as is well 
known, many other symptoms, which are exceptionally attendant on ges- 
tation, and which, when present, are essentially pathological from the 
first. The whole subject, therefore, of the diseases of pregnancy, is one 
to which careful attention should be given ; by the student, in the first 
instance, that he may be able to appreciate the significance of the symp- 
toms which he may observe ; and, by the practitioner, that he may be 
able, in case of need, so to manage a pregnancy with prudence, as to 
avert such dangers as may be foreseen and avoided. There is good reason 
to believe that a sound knowledge of the morbid phenomena of pregnancy 
may enable us not only to avert dangers the nature of which is now well 
understood, but to discover, in the future, means whereby the dangers 
and diseases of development may be combated, by agents not yet at our 
command, and the risks of childbed be thus lessened both to mother and 
child. 

A study, however superficial, of diseases of the womb, or of menstrual 
derangements, shows clearly that a sympathy, of a very intimate kind, 
exists between the uterus and the nervous and digestive systems ; a sym- 
pathy which a knowledge of the origin and distribution of the par vagum 
and sympathetic nerves might already have led us to expect. We can- 
not wonder, then, that, during pregnancy, w^hen the function of the 
uterus is so exalted, this sympathetic action should also be exaggerated. 
The symptoms manifested are infinite in their variety, according to the 
constitution of the individual ; but so deceptive and erratic are they in 
their mode of development, that we can place no dependence on them as 
a guide to the probable progress of a given case. There are instances, 
and these by no means unfrequent, in which the constitution is actually 
improved by the occurrence of pregnancy ; and cases are even observed 
in which the downward course of lingering and wasting disease is 
arrested by conception, and is held in abeyance during its continuance. 
There are, on the other hand, extreme cases, in which the life of the 
woman is actually in danger, not from any acute or organic disease, but 
from the great functional disturbance which, in these peculiar instances, 
pregnancy provokes. The time at which such symptoms as merit the 
name of pathological phenomena manifest themselves varies very consider- 
ably. Some have their origin in the early months, and such will usually 
be found, on careful examination, to be purely sympathetic ; while those, 
on the other hand, which do not call for attention and treatment till to- 
wards the end of the term of gestation, will be found, as a rule, to be 
due to some pressure, or mechanical interference with the functions 
which are disturbed. 

Most modern writers, in considering systematically the disorders of the 
pregnant state, have adopted either the classification of Desormeaux, or 
some modification of it. Following their example, we propose to divide 
the affections in question into the following groups : — 



DIGESTIVE DISORDERS. 213 

1. Disorders of the Digestive Functions. 

2. Disorders of Respiration. 

3. Disorders of the Circulatory System. 

4. Disorders of the Secretions and Excretions. 

5. Disorders affecting Locomotion. 

6. Disorders affecting the Nervous System. 

7. Displacements of the Gravid Uterus. 

I. Disorders of the Digestive Functions. — Vomiting, or rather " morn- 
ing sickness," is, as has already been stated, one of the most constant, 
as it is one of the earliest, of the signs of pregnancy. Indeed, it may 
be said that, owing to the intimate sympathy which has been spoken of 
as existing between the uterus on the one hand and the stomach on the 
other, almost all pregnant women are affected with it more or less. 
Sometimes, this symptom manifests itself almost immediately after con- 
ception — almost always in the course of a few weeks — and it generally 
continues till the period of quickening has been reached. So long as the 
vomiting is moderate, it is best not to interfere ; and, indeed, an impres- 
sion very generally prevails, to which Puzos and others have given ex- 
pression, that it is a salutary symptom, and mid wives have an aphorism 
that " a sick pregnancy is a safe one." But, in some cases, the sickness 
goes to a very great extent, the woman being constantly nauseated, and 
the stomach rejecting almost everything, solid or fluid, which it receives. 
In some of the worst of these cases, it is a matter of constant astonish- 
ment how it is possible for the vital powers to be sustained, as every- 
thing seems to be ejected almost as soon as it is swallowed. Of course, in 
all such, a certain portion of the food must be retained ; or the stomach 
rapidly absorbs a portion before its contents are voided. As a rule, the 
symptom is most violent, and most frequently calls for treatment in the 
case of primiparse ; but it occasionally happens that a woman, who has 
previously been pregnant without any very marked digestive disorder, 
may, on a subsequent occasion, undergo the misery of this affection to 
the fullest extent. There exists, moreover, a great variety in the amount 
of pain or discomfort to which the act of vomiting gives rise — some women ^ 
simply emptying the stomach, without pain or effort, as in the vomiting 
which is symptomatic of brain disease, while others suffer pain and ex- 
haustion from the excessive retching, to an extent which leads us to 
marvel how it is possible, under such continued spasmodic action, for the 
uterus to remain quiescent, and to retain its contents. Even in the 
extreme cases, the emaciation is by no means in proportion to the 
severity of the symptoms, and the development of the foetus goes on 
as steadily as if the system were quite unaffected by any disturbing 
influence. 

In the cases which are most intractable, the matters ejected are often 
mixed with bile, the breath is fetid, and the patient complains of severe 
epigastric pain. The latter has been relieved by the application of a 
small blister to the epigastrium, which may be dressed with morphia. 
The experience of all, however, who have tried opiates seems to be against 
their use, at least by the mouth. Sometimes, quite suddenly, and with- 
out any treatment whatever, the symptoms cease, after having attained 



214 DISEASES OF PREGNANCY. 

their maximum of intensity ; but in other cases they persist, and, if 
not relieved, reduce the woman to the last stage of exhaustion, when 
nature at last interferes for her relief by the occurrence of spon- 
taneous abortion, — a fact which has been generally received as an indi- 
cation of the treatment which we should adopt in extreme cases. There 
is scarcely any form of rational treatment which has not been tried, Avith 
a view to the alleviation of this distressing symptom. We shall only 
mention here, however, such remedies as have been commended by the 
best authorities, or have seemed to us to be the most reliable. Narco- 
tics, as a rule, are worse than useless, if we except chloral hydrate, which 
has sometimes given good results when given by injection. When the 
symptoms are slight and confined to a simple aggravation of the ordinary 
morning sickness, — under which some women are vastly more impatient 
than others, — the remedies employed should be of the mildest possible 
nature, and in many cases some bitter infusion, or a cup of strong tea 
before rising in the morning has quite a decided effect. In many in- 
stances, we have known the nausea to be greatly relieved, and the vomit- 
ing entirely checked by breakfasting in bed, and not rising for some little 
time afterwards. In some, food is only retained when cold ; and in others, 
nothing will lie on the stomach but what is hot. Ice will sometimes check 
it; and bismuth, in doses of eight or ten grains, has been said by Cazeaux 
to have a good effect. It will be obvious from these facts that the manage- 
ment of the diet is an important part of treatment, but one which will 
often perplex us sadly. 

The strictest attention must be paid to the state of the bowels, and 
marked benefit is often derived in cases where they are sluggish in their 
action, from a gentle dose of some such mild laxative as Carlsbad salts, 
PuUna water, or the phosphate of soda. There is, perhaps, no class of 
remedies Avhich is attended with such beneficial results as effervescing 
draughts, among the best of which may be mentioned the granular effer- 
vescing citrate of magnesia. On the Continent a favorite remedy is the 
"potion de Rivi^i-e," which is prepared and given in the following man- 
ner, so that the effervescence actually occurs within the stomach : — 

El 1. Acid. Citric, gr. xxxvi ; 2. Potass, bicarb., gr. xxxvi ; 

Syr. Simp, ^j ; Aquae, §iij. M. 

Aquae, ,^ij. M. 
Sig. A tablespoonful of each to be taken successively. 

Calumba and soda is a favorite combination with some ; and hydro- 
cyanic acid, or creasote, may be tried, although their usual effect is not 
to be depended upon. Salicine has also been mentioned; and the salts 
of cerium have been used and strongly recommended by Simpson, but in 
so far as our experience goes, with no better effect than the other means 
which have been mentioned. Should there be much exhaustion of the 
patient's strength, stimulants must be employed ; and, indeed, these, when 
taken in moderate quantities, and in an effervescing form, such as cham- 
pagne, or brandy and soda water, seem almost to exercise a specific in- 
fluence. In some cases, pepsine is a very valuable addition to other 
modes of treatment. Sometimes, when such of the above measures as 
may have been selected are totally devoid of effect, we stumble fortu- 
nately on some agent which may chance to have the desired effect, even 



TREATMENT OF VOMITING. 215 

though it be of the simplest possible character. Of such a nature is 
milk and lime-water, and barley-water ; indeed, in reference to the latter, 
we have seen such striking instances of its efficacy, in which it has been 
retained by the stomach when all else has been rejected, that we have 
come to look upon it as among the most valuable agents which we have 
at command. Lumbar pain is sometimes associated with the vomiting 
of pregnancy, and it is possible that this may depend upon that slight 
form of uterine inflammation to w^hich Burns refers as a cause of obsti- 
nate vomiting. This affords, at least, a rational explanation of the Cifect 
of fomentations, hot baths, and, if the patient be plethoric, of leeches 
applied to the loias, in arresting the vomiting in this class of cases. A 
beneficial effect is also derived from the use of belladonna, applied either 
to the abdomen, as recommended by Bretonneau, or administered in the 
form of pessaries. In some cases, where the irritability of the stomach 
seems merely to be increased by food and drink, it w411 be proper for us 
to sustain the powers of nature by nutritive enemata ; and, availing our- 
selves, further, of the possibility of ingestion by the skin, we may give 
warm baths, to Avhich gelatinous matter, in any form, may be added ; or 
inunction, by means of cod-liver oil, or other oil, may be practised. 

Dr. Graily Hewitt has attempted to establish, as a part of his system 
of uterine pathology, that the vomiting of pregnancy is due to displace- 
ments, and is to be controlled by appropriate mechanical support, but his 
extreme views on this subject are not likely to command much support, 
although no one doubts that displacement may occasionally be the sole 
cause. Another method of treatment of recent origin is dilatation of the 
OS by the introduction of the finger, and although one would naturally 
fear that such a procedure might become the cause of abortion, a suffi- 
cient number of cases have been recorded to show that the sudden cessa- 
tion of vomiting after dilatation is often very striking.^ 

Failing all other means, the question remains whether we are war- 
ranted in imitating what nature occasionally effects by her own efforts, 
by inducing the premature expulsion of the foetus. We shall not pause 
here to cansider, as some have done at great length, the moral aspects of 
this important practical question. The idea involved is death to the 
foetus, in order either to avoid risk to the mother, or to save her life, 
when that is in immediate and urgent dan^-er : and no risiht-minded man 
can decide in such a case, without feeling that a grave moral responsi- 
bility rests upon his decision. We apprehend that when it is a mere 
question of freeing the woman from the risk of a contingent, though not 
imminent danger, we are in no case warranted in sacrificing the life of 
the child, and we must therefore dissent from the conclusions of those 
who would sanction such a proceeding in any condition of the mother 
short of extreme peril. The conclusion at which Cazeaux and others 
have arrived is, that under no circumstances are we justified in inducing 
premature labor for the relief of the vomiting of pregnancy ; but to this 
we cannot assent, although we admit that the cases which would warrant 
the operation are of extremely rare occurrence. That such cases do 

1 For details as to this procedure, see a paper hy Dr. Edward Copeman : British 
Medical Journal, May 15, 1875. 



216 DISEASES OF PREGNANCY. 

occur we cannot doubt ; but let the young practitioner be assured that a 
life-long experience will scarcely bring such a case under his observation, 
and let him beware, therefore, lest by exaggerating to himself the import- 
ance of the symptoms, he may, in his anxiety, be led into error. For 
his guidance, we would call attention to the following facts : — 

1. Cases have been recorded in which death has undoubtedly been 
the result of vomiting during pregnancy, and of the inanition consequent 
upon it. Two examples of this are narrated by M. Dance, in the " Ar- 
chives Generales" for 182T, where the vomiting began with pregnancy 
and terminated fatally — in the one case at three, and in the other at three 
and a half months. Dubois met with twenty fatal instances in thirteen 
years, and Tyler Smith alludes to two cases '' in which the induction of 
premature labor artificially was so long delayed that the patient died 
before abortion could be induced." Burns, on the other hand, says that 
" he has never known vomiting, purely dependent on pregnancy, end 
fatally ;" and a similar observation is made by Desormeaux. 

2. Numerous cases are recorded in which the operation was success- 
fully performed, with immediate relief of the symptoms. Such instances, 
however, wdiile they afford proof of the safety of the operation, are not 
to be admitted as, in any sense, arguments in favor of the practice ; 
moreover, the result alluded to is far from being invariable. 

3. Instances have occurred, in the experience of almost every practi- 
tioner, in which the symptoms, although of great severity, spontaneously 
ceased, and the labor reached a happy termination ; and not a few are 
recorded, on excellent authority, which show that, at the last moment, 
and in the most desperate case, the vomiting may cease, and an equally 
satisfactory result ensue. In illustration of this, we may cite the follow- 
ing example, which occurred in the practice of Dubois: — 

" A young Grerman lady, two and a half months pregnant, had vomited almost in- 
cessantly from the first fortnight of her pregnancy. For six weeks she vomited every 
few minutes, and the smallest spoonful of fluid set up at once the most energetic con- 
tractions of the stomach. She was excessively emaciated and feeble ; her breath was 
very fetid. In a word, the symj)toms were so grave that M. Dubois called in Chomel. 
The prognosis of both was almost hopeless, and they left the lady, in the belief that 
she had but a few days to live. Two days after the consultation, the patient was 
seized with severe diarrhoea, and from that moment the vomiting ceased, and never 
returned. She could then take and retain some nourishment, the quantity of which 
was gradually increased until she regained her strength and full digestive powers." 

This woman, then, after being so near death that two such men con- 
sidered it a hopeless case, made a perfect recovery, and carried her child 
to the full term. Dubois gives, quite frankly, the details of two similar 
cases, in which he proposed abortion. In both the women refused, and 
went to the full term. 

A review of facts such as these should certainly lead us to use the 
greatest possible caution, when the question of premature labor comes, 
in such cases, under our consideration. It is unfortunate that the great 
majority occur in the early months of pregnancy — a fact which increases 
our responsibility. For, if it were essentially a disease of the last, in- 
stead of the first weeks, we might provoke labor with less hesitation, as 
we would then have a viable child, instead of an embryo whose expulsion 
involves its death. The special circumstances which attend each case 



DIGESTIVE DISORDERS. 217 

should be taken anxiously into consideration, and we should certainly say 
that, seeing that dilatation of the os and cervix may be made the first 
stage in an operation for causing abortion, we should, even in the most 
extreme case, always pause at that stage, and only proceed to what in- 
volves inevitable abortion when dilatation alone has failed. 

Among the other disorders of digestion to which pregnancy gives rise, 
Anorexia is sometimes prominent. The lack of appetite, amounting oc- 
casionally to actual disgust and loathing, is most marked in the early 
months, although not confined to that period. It is to be met by very 
careful attention to the normal functions, and by regulation of diet. 
The effect of tonics, although occasionally good, is not to be depended 
on ; and it must always be remembered, in reference to the treatment of 
this and other disorders of the same class, that although we may mitigate 
symptoms and deaden sensibility within certain limits, we cannot annihi- 
late the sympathy upon wJiich the manifestation of these phenomena 
depends. It is far from unusual for the appetite to become depraved in 
a manner similar to what occurs in chlorosis ; and this, in an aggravated 
form, constitutes the affection known as Pica. What usually occurs in 
healthy pregnancy is, that the appetite is altered but not depraved, milk, 
fresh fruits, succulent vegetables, and other articles of diet easy of diges- 
tion being the form of "longing" which prevails. But when this takes a 
morbid direction, we find the desire for such substances replaced by a 
craving for raw rice, soap, chalk, cinders, slate pencil, and even sub- 
stances more disgusting. If the morbid longing be for such matters as 
may be prejudicial to health, they must of course be withheld, even by 
forcible means should this be necessary. It is, however, usual, and is 
certainly judicious, to humor the tastes as far as is possible, as they not 
unfrequently point to the class of diet which agrees best with the 
patient. 

Gastrodynia and Pyrosis, if present in any marked degree, must be 
treated by precisely the same means which we would adopt in the same 
affection occurring in other circumstances ; and for this purpose bismuth, 
calumba, and antispasmodics, combined if necessary with minute doses 
of opium, may be prescribed. In heartburn and acidity, Dinneford's 
fluid magnesia, or the effervescing citrate or bicarbonate of potash may 
be administered in each case with every prospect of at least temporary 
relief to the symptoms. Constipation is a very frequent concomitant of 
pregnancy, and is due to the pressure which is exercised by the pregnant 
womb upon the bowels, thus not only reducing its calibre, but also para- 
lyzing to some extent its muscular fibres. In other cases, there is a 
want of bile, and they who hold that there is during pregnancy a pseudo- 
anaemic state of the system, attribute the irregularity of the bowels to 
the same causes which operate in the early stage of chlorosis. In any 
case, whatever the cause may be, constipation is of constant occurrence, 
and women who were not previously of a costive habit frequently require 
laxatives during the whole course of their pregnancy. If clay-colored 
stools indicate that the function of the liver is interfered with, a few 
grains of blue pill given occasionally will often do much good. In the 
opposite condition of diarrhoea, which is by no means unfrequent, we 
must be careful to discriminate the nature of the case before pushing 



218 DISEASES OF PREGNANCY. 

astringent treatment too far. If it depends upon fecal accumulation, or 
upon the presence of irritating matter in the alimentary canal, the first 
step in the treatment must be to clear out the bowels by castor oil, and 
then to exhibit, if necessary, such astringents as the nature of the case 
seems to call for. 

IT. The Disorders of Respiration, which accompany pregnancy, are 
by no means numerous. Dyspnoea is an affection which is very common 
in the later months, and is then due to the mechanical pressure exercised 
in the direction of the diaphragm by the expanding womb. Rest, care- 
ful attention to the digestive functions, and such arrangement of the dress 
as may tend to encourage thoracic, and relieve diaphragmatic respira- 
tion, are the obvious and sole means by which this affection is to be com- 
bated. In the last Aveeks, the falling down of the womb which then 
occurs, will generally be found, by relieving the diaphragm from pressure, 
to put an end completely to the discomfort from which the patient suffers. 
Dyspnoea may, however, exist at any period of pregnancy ; and, when it 
occurs in the earlier months, it is probably due to sympathetic irritation 
communicated through the nerves. We have known the dyspnoea under 
these circumstances to be very harassing, and in one instance it was 
accompanied, during the first five months, with severe spasmodic asthma 
in the case of a lady who never sufi"ered from that affection either before 
or since. Antispasmodics are obviously indicated in such a case, and, in 
the instance in question, great benefit was derived from a combination of 
chloroform with bromide of potassium. Cough, the result apparently of 
mere sympathetic irritation, is also an accompaniment of pregnancy in 
no small number of cases. It may be found to be associated with con- 
gestion of the base of the lungs, or with some more serious affection of 
these organs. As a rule, it exists independently of any ascertainable 
puhnonary disorder, but it is, nevertheless, frequently spasmodic, and at 
times so violent as to resemble whooping-cough ; and in these cases it may 
induce abortion. Some combination of sedatives and antispasmodics 
would be the best form of treatment for such a case, — the symptoms of 
which are often specially troublesome during the night, — and by pro- 
moting sleep, may prevent exhaustion and constitutional disturbance. 

III. Disorders of the Circulatory System. — Careful analyses have 
been performed in order to determine the condition of the blood during 
the pregnant state. Among these, the researches of MM. Andral and 
Gavarret are conspicuous for the care with which they were conducted, 
and the interest which attaches to the results they disclose. They showed 
clearly that the plethoric condition of the circulation, which had been 
believed in by past generations of practitioners (and which was often 
treated by the ever-ready lancet), did not exist; and not only this, but 
that the condition which was to be observed in the greater proportion of 
cases was more of an anaemia than a plethora. The fact is that, as a 
rule, an examination of the blood of a woman who is pregnant discloses 
alterations in the relative proportion of its constituents, which are closely 
analogous to what we may observe in anaemia from any cause. In the 
earlier months of pregnancy, it would appear that the blood deviates 
little from the normal standard, that the corpuscles are present in their 
usual number, and that the fibrine and albumen are scarcely altered in 



CHANGES IN THE BLOOD. 219 

the proportion ^vhich they bear to the other constituents, the former being, 
if anjthinir, rather diminished. In the hiter months, however, the blood 
is characterized by a remarkable diminution in the number of red cor- 
puscles, and a considerable increase in fibrine, while the proportion of 
albumen suffers no marked disturbance, what little change there is being, 
however, a diminution. An estimate has been made bj the same observ- 
ers, according to which they assume, that if we suppose the average 
number of corpuscles in the blood of healthy women who are not pregnant 
to be represented by the number 125, the average in women towards the 
end of pregnancy is probably not more than 115. If, in like manner, we 
take 300 as representing the physiological average of the fibrine, the 
proportion of that constituent up till about the sixth month may be set 
down at 250, while from this period onwards, during the last three months 
of gestation, it steadily increases in quantity, and reaches as high in ex- 
treme cases as 480. These physiological phenomena accord perfectly 
with the small clot and the buffy coat which have been so generally ob- 
served while practising venesection in the course of a pregnancy, and are 
further interesting in connection with the occurrence of thrombosis in the 
pregnant state. The interpretation, however, which was formerly attached 
to this, was that the appearance was due to an inflammatory condition of 
the blood, and was consequently evidence that bleeding was rational and 
judicious; but now, a more correct knowledge of true physiological prin- 
ciples enables us to recognize that such an appearance is simply due to 
the alterations which have been mentioned. In addition to the facts above 
noted as the result of analytical research, it has been further established 
more recently that the quantity of iron, as we would naturally expect 
from the loss of red corpuscles, is decidedly diminished. 

Many of the symptoms of pregnancy, it must be admitted — such as 
somnolence, weight in the head, flushing, ringing in the ears, and vertigo — 
bear a striking resemblance to those which indicate plethora. As the 
lancet has, however, in this country fallen into disuse, it is unnecessary 
to repeat that such symptoms are no indication whatever for bleeding. 
There is, indeed, much reason to believe that the errors of a former 
generation have in this, as in some other respects, led to the absolute re- 
jection of what is a powerful agent in the treatment of disease, and that 
in avoiding one extreme we have gone to the other. We cannot doubt, 
however, that in the treatment of the pregnant state the change has had 
a beneficial result, for with the blood in such a state as it is now demon- 
strated to be in the later months of pregnancy, no one, even in former 
times, would have thought of bleeding in an ordinary case of gestation. 
The analogy between pregnancy and chlorosis is most elaborately argued 
and worked out by Cazeaux, who goes so far as to assume that the system 
during pregnancy is in a state closely resembling ansemio-chlorosis, and 
that the treatment of pregnancy should in a great measure be based on 
a knowledge of this fact. "An animal diet," he says, " and the admin- 
istration of chalybeates have for many years seemed to me to be as useful 
against the funcdonal disorders of pregnancy as against those of chlo- 
rosis." 

We cannot, however, admit, as Cazeaux seems to do, that an affection 
identical with chlorosis is a usual and normal condition of pregnancy. 



220 DISEASES OF PREGNANCY. 

To do SO would be to admit that a pathological state is the normal accom- 
paniment of a physiological function, a view which we are certainly not 
prepared to accept. That the phenomena are so far identical has been 
proved, but there are other explanations which may be offered, more in 
accordance with such analogies as may be drawn from known physiological 
and pathological laws. We may, for example, accept it at least as 
possible that the demand which is, during pregnancy, made upon the 
mother to supply the material necessary for the rapid development of the 
infant which she carries, may of itself cause what we are accustomed to 
consider a deterioration in the constitution of the blood. And yet this 
so-called deterioration may, for aught we know, be a wise provision of 
nature against the time when this demand shall suddenly cease. Indeed, 
although we have little fancy for theories in support of which we have no 
facts to advance, we do think that it is by no means improbable that the 
vital engine is, for a special purpose, worked at a low power during the 
last months of pregnancy. In this way at least, the tendency to post- 
partum inflammatory action may be diminished, as it is only by degrees, 
after labor, that the blood regains its normal and healthy composition. 
Or, again, this pseudo-chlorotic state may be in a great measure induced 
by inadequate nourishment, the result of the nausea and anorexia which 
so frecpiently occur. But, whatever the cause of the alteration of the 
blood may be, it is very doubtful whether iron can with propriety be 
administered in most cases of pregnancy. In certain cases in which spe- 
cial circumstances have induced us to prescribe it, we have found that its 
effect was less satisfactory than usual ; and that it did not allay digestive 
disorders, but rather, from its tendency to increase the sluggish action of 
the bowels — which is so frequently a complication of pregnancy — seemed, 
in some cases at least, to ao;o;ravate them. 

In thus opposing the view that pregnancy should be treated as a dis- 
ease, when it presents what we recognize as its normal condition, we 
must guard ourselves from the possibility of misconception. There are 
cases, undoubtedly, in which the symptoms are such that we are bound 
to look upon them as cases of chlorosis ; nay, we may go further, and 
admit that such cases are by no means of very rare occurrence. Cir- 
cumstances render it highly probable that many of the signs of pregnancy 
are intimately associated with the diminution of the blood-corpuscles al- 
ready alluded to, but it seems somewhat curious that these symptoms are 
often present during pregnancy, while the healthy ruddy complexion of 
the patient discourages the idea of chlorosis. In accounting for this, 
we must bear in mind, as Scanzoni observes, " that there is a form of 
chlorosis in non-pregnant women, in which the patients, in spite of the 
fact that the relative quantity of blood-corpuscles has undergone dimi- 
nution, preserve a quite healthy color, so that it is conceivable that, in 
pregnant women also, the pale color of the general surface is no patho- 
gnomonic sign of a diminution of the blood-corpuscles." To this we 
would only add, that it consists with the experience of all that pallor is 
quite as frequent in the early as in the late months of pregnancy, although 
in the former case the alteration in the relative proportion of the blood- 
corpuscles is as yet scarcely if at all disturbed. 

In a certain number of instances, however, the deterioration of the 



CHANGES IN THE BLOOD. 221 

blood takes place at an unusually early period, and, running its course 
•with great rapidity, leaves the woman, before many weeks have passed, 
in a state in which all the symptoms of chlorosis in its higher grade may 
be manifested ; and those symptoms are all the more marked when the 
chlorosis has preceded conception. In all such cases, the course of 
gestation is more or less disturbed by the characteristic symptoms of the 
disease, and an influence is not unfrequently exercised upon the duration 
of pregnancy by the occurrence of exceptionally violent symptoms, which 
may give rise to premature delivery. The experience of those who have 
devoted most attention to this subject seems to show that no hurtful in- 
fluence is exercised by chlorosis on the progress of labor, but that a 
common result is that convalescence is greatly protracted, and that there 
exists an increased tendency to hemorrhage. In such cases, also, it has 
been remarked that there is an increased liability to diseases which are 
the sequeh^ of labor, such as Phlegmasia Dolens ; and, in the case of 
epidemic Metria, that disease is apt, when it attacks a chlorotic woman, 
to assume some one of its more rapid and fatal forms. The treatment of 
the chlorosis of pregnancy is to be conducted on the same principle as 
under other circumstances. It will thus consist mainly in careful atten- 
tion to the general health, special attention being given to the diet, which 
should in all cases be generous, and contain a considerable proportion of 
animal food. Stimulants in some form are also indicated, the red wines 
of Bordeaux, Burgundy, and Hungary being, perhaps, superior to all 
others in the treatment of this class of diseases. In this respect, how- 
ever, tastes as well as constitutions vary considerably, but, as a rule, the 
milder stimulants will be found to suit better than those of greater alco- 
holic strength, unless, indeed, sinking, or even collapse, the result, it 
may be, of some form of hemorrhage, should call for more energetic 
measures. The only class of medicines which stand prominently in ad- 
vance of others in the treatment of chlorosis are, of course, the various 
preparations of iron, which should therefore in every case be tried. If 
the bowels are constipated, the iron should be combined with a laxative ; 
but our own impression is, as has already been observed, that it is, as a 
rule, less efficacious in pregnancy than under other circumstances. 

Plethora, in its wider sense, is a comparatively rare affection of preg- 
nancy. Local Plethora or congestion is, of course, common enough, and 
is the result generally of mechanical pressure, exercised either upon the 
organs aff"ected or upon venous trunks. A certain number of cases do, 
however, actually occur in those whose temperament renders them liable 
to hyper^emia. In those instances, the symptoms of pregnancy are dif- 
ferent from such as are ordinarily observed, but are by no means ren- 
dered more bearable. In fact, the vertigo, ringing in the ears, flushing, 
and severe headache greatly aggravate the discomfort of the woman. If 
these indications are disregarded, and the symptoms unchecked, nature 
may relieve herself by the spontaneous occurrence of hemorrhage ; and, 
if the flow of blood should take the direction of the utero-placental, or 
utero-decidual system, a very natural result will be the premature expul- 
sion of the iodtns or embryo. The treatment proper to such cases will 
consist, in the milder form, of simple regulation of the diet and mild 
laxatives. We must not here, as in the chlorotic cases. 



222 DISEASES OF PREGNANCY. 

patient to use animal food with freedom ; but, on the contrary, we must 
enjoin abstinence, complete if need be, from such articles of diet, and 
even from the milder stimulants, — light soups, cooling drinks, and a large 
share of vegetables being substituted for more stimulating materials. 
Our object here is to keep the supply in proper balance with the assimi- 
lative powers, so as to reduce the tendency to hypergemia ; and our 
efforts in this direction will be greatly aided by the use of laxatives, of 
which the salines are the best for the purpose, beginning, perhaps, in 
the first instance with a more active cathartic. When the symptoms are 
so severe as to lead us to apprehend serious results, such as convulsions, 
we may fearlessly have recourse to blood-letting, Avhich may be practised 
from the arm in the usual way ; or, if there be evidence of a special 
determination of the blood in any one direction, such as the brain, the 
kidneys, or the womb, local abstraction of blood by leeches or cupping- 
glasses may in these instances be preferred. In such cases the bleeding 
must be followed by the general treatment above indicated, which should 
be rigorously maintained, it may be continuously, or at such intervals as 
seem necessary, during the whole course of the pregnancy. 

The pressure which, during the pregnant state, is exercised upon 
venous trunks, gives rise to a number of symptoms which are thus due 
to a cause purely mechanical. Among the more common of these is a 
varicose condition of the veins of the legs and lower part of the trunk, 
which, when trifling, may be disregarded, but, when severe, should be 
treated by bandages, the pressure of which must be carefully regulated. 
Should this condition of the veins have preceded impregnation, the symp- 
toms may be so severe as to suggest to the mind the possibility of relief 
by some operation with a view to a radical cure. It need scarcely be 
said, however, that, under the circumstances of pregnancy, the chance of 
a favorable result from any such operation is extremely improbable ; and 
moreover, the immediate effect of the operation might be to disturb the 
progress of gestation. Hemorrhoids spring from the same mechanical 
cause as the preceding affection, and are besides very greatly aggravated 
by the habitaal constipation which is of such frequent occurrence during 
pregnancy. However severe the suffering may be to which they give 
rise, there are scarcely any circumstances which would warrant us in 
excising, ligaturing, or otherwise operating with a view to the cure of 
this troublesome affection. Nor is it proper even to apply leeches to the 
part, if it be true, as has been asserted, that these may cause abortion ; 
and, besides, Desormeaux tells us that he has never known the applica- 
tion of leeches to, or incision of, these tumors in pregnancy attended 
with any durable amelioration in the symptoms. The treatment of 
hemorrhoids must consist, therefore, in measures which are purely pal- 
liative. If they are painful, sponging with warm water, or fomenting 
with sponges wTung out of hot water and applied successively as hot as 
can be borne, is often attended with the greatest possible relief and com- 
fort. Of local applications, nothing perhaps is superior to the well known 
Unguentum Gallge cum Opio. Where hemorrhage is a prominent symp- 
tom, it may be necessary to employ more active astringents, but what 
is more useful is cold injections, which may be quite freely used without 



VAGINAL THROMBUS. 223 

risk.^ It is doubtful whether cold hip-baths are advisable, as the risk in 
that case of exciting uterine action is increased. 

We have already observed, as a sign of pregnancy, the distended con- 
dition of the small veins of the vagina, which gives rise to an alteration 
of the color of the part to a different tint. If the pressure be unusually- 
great, these veins may assume a varicose appearance, but if this only is 
the result, no interference is necessary, and the inconvenience is but 
trifling. In another and more severe class of cases, rupture of the dis- 
tended vessels takes place, and the result is the formation of a livid 
tumor, usually limited in extent, and situated for the most part in one or 
other of the labia. This tumor constitutes a Thrombus of the vagina. 
Its appearance, Avhich is usually sudden, is attended with considerable 
pain, and its immediate cause, in many instances, is to be traced to 
blows, falls, or violent efforts of any kind. It is very variable in its 
course and termination, and may end by resolution like a thrombus in 
any other situation, in which case it is of very short duration. It may 
terminate also in rupture, which gives exit to the pent-up blood, and may 
thus give relief and lead to a speedy cure ; or the hemorrhage may be so 
excessive as to cause great apprehension, and it has even terminated in 
death. In other cases, suppuration and gangrene have been the imme- 
diate effects, and from the latter process a fatal result has also ensued. 
The condition of the parts during pregnancy renders this affection more 
serious than when it is independent of the process of gestation, and it is 
not until delivery has taken place that Ave can look for cure. This is, 
however, by no means always the case, for the relaxation which then 
occurs facilitates the further effusion of blood, and we may therefore 
have, immediately after delivery, a serious increase in the bulk of the 
tumor. For a similar reason, thrombus is occasionally developed for 
the first time after labor, and in these cases there is more danger of its 
acquiring a considerable size. 

The treatment of vaginal thrombus is a point of great nicety and im- 
portance. In those cases in which there seems to be a tendency towards 
resolution, and in which the density of the tumor becomes increased while 
its bulk diminishes, no active interference is called for, and our duty is 
simply to watch the progress of the case, lest circumstances should arise 
to call for prompt action. In cases, on the other hand, where the tumor 
is of large size, so as to fill a considerable portion of the pelvis, and form 
an obstacle to the functions of surrounding parts ; or when it is fluctu- 
ating throughout, showing that it contains a vast reservoir of fluid blood, 
and when there is reason to believe that the hemorrhage into the tissues 
is still going on ; or, again, when there is pointing and other evidence 
that at any moment spontaneous rupture may occur — and in all these cases 
evidence that the vital powers are on the wane — we cannot hesitate, but 
must act by at once incising and giving vent to the effused blood. The 
two groups of cases above cited are extremes, but there is another, form- 
ing probably the largest number of all, which maybe supposed to occupy 

I Cazeaux recommends the administration every night of a full enema, to be given 
cold, and when this has been evacuated, a second is to be given, about a fourth of 
the bulk of the first : the second to be retained. 



224 DISEASES OF PREGNANCY. 

a place intermediate between them. In this class, while the symptoms 
are neither such as to make us confident in the approach of resolution 
nor to cast aside as injudicious the idea of further delay, we are con- 
strained to wait, with varying hope and apprehension, as long as the health 
of the woman will admit of it, until the features of the case become so 
marked in one direction or another that our course of procedure is defi- 
nitely fixed. A special class of cases are those in which a thrombus 
during labor threatens to be an actual impediment to its progress, and in 
which, for that reason, irrespective of others, it may be necessary to 
operate. 

In all cases in which incision has been determined upon, we must in the 
first place take care to make the aperture a free one, for if a small opening 
only is made, nothing will escape but fluid blood, and all the clots, which 
constitute probably the greater portion of the bulk of the tumor, will be 
left behind. If the clots are adherent, or firmly inclosed in the inter- 
stices of the tissues, care must be taken in dislodging them, lest we should 
unnecessarily give rise to fresh hemorrhage. As regards the point of 
the tumor at which we are to operate, we must, in the first instance, be 
guided by the fact whether or not there is any indication of pointing, and, 
if so, our choice must fall upon the site so indicated. But if there be no 
pointing, and seeing that the thrombus is very generally situated in the 
labia, and has thus a cutaneous and a mucous surface, the question arises 
through which of these is the incision to be made. On this point, most 
of those who have written on the subject are agreed that to make the 
opening from the cutaneous side gives the patient the best chance. The 
freer exit for the discharges, the protection of the wound from the lochial 
and other irritating fluids, and the improbability of there being in future 
labors a cicatrix which might again give way, are among the reasons 
which have been urged in favor of this mode of procedure. The inflam- 
mation which usually supervenes upon theo peration must be combated 
by appropriate means, such as strict cleanliness, and suitable lotions and 
injections. The prognosis of all such cases is far from favorable. " Of 
sixty- two cases," says M. Deneux, " which have come to my knowledge, 
the w^oman died in twenty-two, either during pregnancy, or labor, or 
afterwards. And, with the exception of one case, all the children of 
these twenty-two women died."^ 

' Under the head of disorders of the circulatory system may be mentioned a sub- 
ject which has of late years attracted considerable attention, chiefly on the Continent, 
viz., the relation which subsists between pregnancy and disease of the heart. See 
on this subject a singularly able work by Dr. Angus Macdonald, " The Bearings of 
Chronic Disease of the Heart upon Pregnancy, Parturition, and Childbed." London, 
Churchill, 1878. 



DISORDERS OF SECRETION AND EXCRETION. 225 



CHAPTEE XIV. 

DISEASES OF PREGNAI^CY (Continued). 

IV. Disorders of Secretion and Excretion. — Ptyalism. — Interference witli 
Function of Kidneys and Bladder.— Retention of Urine: Mechanical or from 
Paralysis. — Albuminuria : State of the Blood in : Peculiarities of the Puerperal 
Form: Connection of with Puerperal Convulsions: Symptoms, Prognosis, and 
Treatment. — The Phosphatic Diathesis in Pregnancy. — Leucorrhoea and 
Granular Vaginitis. — Ascites. — Dropsy of the Amnion. — Hydrorrhcea. V. 
Disorders affecting Locomotion. — Pelvic Articulations: Relaxation of 
Inflammation of. YI. Disorders affecting the Nervous System. — 
Afections of the Special Senses. — Effect on the Moral and Intellectual Facul- 
ties. — Abdominal and Uterine Pain. VII. Displacements of the Gravid 
Uterus. — Prolapsus. — Anteversion and Anteflexion: Symptoms and Treat- 
ment of. — Retroversion; how caused originally: Chronic and Acute Forms : 
Symptoms and Treatinent of each: Operation for the Reduction of. — Oblique 
Displacements. 

IV. Disorders of Secretion and Excretion. 

Ptyalism, which has already been mentioned as a concomitant of 
pregnancy, is occasionally excessive, and may thus give rise to such 
annoyance as to cause the woman to apply for relief. It has generally 
been observed as an affection of the first weeks of pregnancy only, and 
rarely lasts more than two months : if it be excessive, or of longer dura- 
tion than usual, it may be relieved by the use of gum arable, tamarind 
water, ice, or some gentle astringent. 

The Function of the Kidneys is not, as a rule, in any way disturbed 
by gestation.^ It is, however, otherwise as regards the Bladder, which, 
from its situation, is peculiarly liable to be affected in its function by the 
pressure to which it is subjected. Annoyance from this source is seldom 
experienced in the early months of pregnancy, but, in the last weeks, 
when the uterus has fallen downwards, as is usually the case prior to 
delivery, the pressure then brought to bear upon the neck of the bladder, 
which is compressed between the head of the child and the symphysis, 
may give rise to intolerable annoyance, for the relief of which prompt 
action is frequently required. In many cases, the woman is able to re- 
lieve herself perfectly by placing herself on her knees and elbows, when, 
the weight of the child being transferred to the fundus of the womb, the 
mechanical obstacle is at once removed, and she is able to micturate 
without difficulty. The cases in which the greatest amount of difficulty 
exists are those which are accompanied by anteflexion of the womb, when 

^ The formation of Kyesteine lias already Ibeen referred to. — See "Signs of Preg- 
nancy." 

15 



226 DISEASES OF PREGNANCY. 

the pressure upon the bladder is for obvious anatomical reasons more 
severe. Complete retention of urine is occasionally the result, and, in 
such a case, the bladder may become enormously distended, and, in an 
unnaturally elongated form, may reach as high as the umbilicus ; and, 
indeed, cases have been recorded in which death has taken place from 
rupture of the bladder, and escape of the urine into the peritoneal cavity. 
Fortunately, however, it is only on rare occasions that the retention is 
complete, but it is by no means unusual for the practitioner to be sum- 
moned to relieve the almost constant irritation from which the woman 
suffers, in consequence of the difficulty which she experiences in her 
efforts to empty the bladder. If this difficulty is not relieved by change 
of posture during the act, an abdominal bandage, carefully adjusted, and 
worn so as to give support to the uterus, will often be productive of the 
most satisfactory results. But, failing such means, it will be necessary, 
in some instances, to use the catheter, and in this manner to relieve the 
bladder. With the ordinary female catheter, considerable difficulty may 
often be experienced, as it is too straight and too short to be adapted to 
the altered anatomical relations of the urethra and bladder; and, indeed, 
its use is not free from risk. It is, therefore, much better to use an 
elastic catheter, by means of which the operator will, even in cases of 
complete retention, rarely fail to effect his purpose. In cases where the 
compression is comparatively trifling, it may act in another way, by in- 
ducing paralysis of the sphincter vesicae, and a constant escape of the 
urine drop by drop. In one case, this was observed by Scanzoni as 
<early as the third month, and disappeared entirely so soon as the uterus 
had risen out of the pelvis in the fourth. Catheterism may be employed 
;as often as is necessary ; and the catheter may be left in for several 
hours, while the woman lies quietly on her back, should the symptoms 
not yield to the simple emptying of the bladder. Sometimes, in the last 
months, she experiences a smarting or more severe pain, in micturating, 
which has been found to depend, in many instances, upon a catarrh of 
the bladder, or at least of its neck ; under which circumstance, whitish 
flakes and purulent matter in the urine will disclose the nature of the 
case, for the treatment of which, the only safe means which can be 
adopted are baths, bland drinks, and emollient applications. This affec- 
tion may be associated with spasm of the neck of the bladder, which may 
also exist independently of any local disease, the irritation which causes 
it being sometimes due to pressure, and at other times to a reflex irrita- 
tion starting from the uterus. 

The existence of Albuminuria as a disease of pregnancy, was first dis- 
covered by M. Rayer, and in this country was brought under the notice 
of the profession by Dr. Lever. Previous to this, there can be no doubt 
that many cases were set down simply as instances of oedema, due to 
pressure (the (Edema Gravidarum of the old writers), Avhich were, 
nevertheless, due to albuminuria or to the changes in the kidneys upon 
which that symptom usually depends. Under ordinary circumstances, 
the habitual presence of albumen in the urine is looked upon as sympto- 
matic of very serious organic disease, and experience shows that we have 
only too good reason to look forw^ard in such cases with somewhat 
gloomy anticipations as to the future. There are, however, exceptional 



THE EXISTENCE OF ALBUMINURIA. 227 

instances, such, for example, as arise in the course of scarlatina, in which 
our prognosis is vastly more favorable. A knowledge of these facts has 
given rise to numerous speculations as to the nature and exact import of 
the symptom, when it is observed in the course of pregnancy. The ques- 
tion, in fact, is — are we to consider the albuminuria of pregnancy as 
indicative of serious disease of the kidneys; or, are we, on the other 
hand, to look upon it as an exceptional symptom of pregnancy, and one 
to the disappearance of which after delivery we may confidently look 
forward? In considerino^, in the lio;ht of modern investio;ation, what 
answer should be given to this query, we note, in the first place, the fact 
that the albumen in the blood is somewhat diminished during pregnancy. 
Along with this we have the researches of Blot and Litzmann, who, by a 
series of independent observations, have shown that albumen exists in 
the urine in more than twenty per cent, of pregnant women ; and, in the 
case of primiparge, the percentage is considerably higher even than this. 
If we were to admit, therefore, that albumen in the urine was here a 
pathognomonic sign of equal significance with that which occurs inde- 
pendently of gestation, we must conclude that the mortality of pregnancy 
and childbed would be thereby in a very great degree augmented. But, 
as experience shows us the contrary, we are thus, on the very threshold 
of the inquiry, forced to admit that the albuminuria of pregnancy is com- 
paratively an innocuous disease. 

That childbed mortality is, directly or indirectly, increased in some 
measure by the presence of albumen in the urine, and the associated 
phenomena, is a fact which no one in these days will gainsay. Among 
the phenomena here alluded to are puerperal convulsions, a subject to 
which we shall, at a later period, have occasion specially to refer, as the 
affection in question is one upon which the most serious results not unfre- 
quently ensue. This is, in fact, one of the most interesting and practi- 
cally important points in connection with the subject ; to the demonstra- 
tion of which Simpson contributed in no small measure, by establishing 
the intimate association which exists between convulsions and albuminu- 
ria. But, the unhappy results which frequently attend this complication 
fortunately do not indicate the ordinary course of an uncomplicated case 
of albuminuria in pregnancy. The frequency with which this alteration 
of the urine is to be observed, as has been shown by the observations of 
Blot and Litzmann already referred to, is sufficient to prove that a large 
proportion of cases are unattended by any marked symptoms, and, there- 
fore, we may assume, run their course without the nature of the case 
being so much as suspected. And, moreover, this idea receives the 
strongest possible confirmation from the fact which experience has fully 
disclosed, that, in the majority of cases in wdiich albumen is actually de- 
tected in the urine by chemical examination during gestation, the general 
health is little if at all aftected, and the normal constitution of the urine 
is restored within a short period after delivery. 

The symptoms of this afi'ection are, then, in the mildest cases, either 
such as to attract no attention, or are confounded with those which 
naturally arise from, or are associated with, the pregnant state. When, 
however, dropsical eff'usion takes place, — which is not, like that which 
has already been alluded to as the result of mere mechanical pressure, 



228 DISEASES OF PREGNANCY. 

confined to the lower limbs, but affects more or less extensively the whole 
body, — our suspicion should be at once aroused, and a careful examina- 
tion instituted, w^hen the presence of the abnormal element in the urine 
will usually be detected. In extreme cases, the legs are enormously 
swollen, and the vulva and vagina tumefied ; and the characteristic puffi- 
ness of the face, with swelling of the upper limbs and of the abdominal 
walls, indicate still more clearly the nature of the case. The urine is 
scanty, of high specific gravity, and may become solid on boiling. In 
the worst cases, and especially in those in w^hich convulsions occur, there 
is considerable headache, dimness of vision, and amaurosis, — which latter 
sometimes comes on quite suddenly, immediately before a fit. The blood 
poisoning, which gives rise to these epileptiform seizures consists, as the 
observations of Christison and others have conclusively shown, in the 
presence in the blood of urea, which is not eliminated in consequence of 
the perverted condition of the renal function. It has been demonstrated 
experimentally, that placing a ligature on the renal veins, and thereby 
disturbing the balance of the circulation in the kidneys, causes the ap- 
pearance of albumen in the urine. From this the inference has been 
drawn, that the albuminuria of pregnancy w^as due to the pressure exer- 
cised by the gravid uterus. That this is the case in many instances we 
cannot doubt, but at the same time we are inclined to believe that the 
explanation has been too readily accepted as the solution of every case. 
The fact of its greater frequency in primiparse and in twin pregnancy, 
where the pressure is obviously greater, no doubt lends confirmation to 
the view alluded to ; but, on the other hand, instances occasionally occur 
in which, at an early period of pregnancy, albumen may be detected 
before any such pressure as would account for it on the above hypothesis 
could by any possibility occur. " In such cases," says Dr. Tyler Smith, 
" the disease appears to me to depend upon reflex irritation of the kid- 
neys by the gravid uterus, similar to the irritation of the salivary glands, 
the mammae, thyroid, etc., and not upon mere pressure alone." If the 
symptoms continue unchecked, the general health of the patient becomes 
seriously compromised. The anaemia and waxy pallor which are so 
characteristic of the more advanced stages of Bright' s disease now be- 
come manifest. 

The existence of puerperal albuminuria is, as a rule, only recognized 
during the last months of pregnancy. It by no means follows, however, 
that this marks the period at which it is first present in the urine. On 
the contrary, we may be certain that its recognition is often deferred to 
that period, simply because the symptoms have not been such as to attract 
particular attention. There is too good reason to believe, indeed, that 
even in cases where the symptoms ought to have excited suspicion, the 
idea has never been entertained until the occurrence, during labor, of 
violent convulsions, for the first time directs attention to the fact. The 
greatest variety exists in the progress and duration of the disease. In 
some of the cases which have been most carefully noted, the presence of 
the albumen has not been constant, but has either oscillated in regard to 
quantity, or has ceased completely for days, to return again, — thus re- 
peatedly intermitting during a considerable period. In others, the affec- 
tion appears to gain ground as the pregnancy advances, and ultimately 



ALBUMINURIA. 229 

to culminate in chronic Bright's disease, either in the course of the exist- 
ing pregnancy or at a still later period. There are, of course, cases in 
which women who are already the subjects of Bright's disease become 
pregnant, and in whom all the symptoms suffer aggravation. But what 
we refer to at present exclusively are those cases in which, at some period 
in the course of a pregnancy, albuminuria makes its appearance for the 
first time. The instances in which no serious kidney lesion exists, con- 
stitute, happily, the great majority. In such, the albumen usually dis- 
appears shortly after delivery ;^ but, in others (as we not unfrequently 
see after scarlatina), the albumen persists for many months, although the 
general symptoms are not necessarily severe. Much information maybe 
derived, in doubtful cases, from a microscopic examination of the urine : 
and in this way, too, our prognosis will, in a great measure, be formed, 
as the presence of tube casts, and their microscopic characters, will often 
reveal the nature and stage of the renal degeneration, should it exist. 
Headache, sickness, and the various forms of digestive disorder which are 
so frequently associated with pregnancy, are, under the influence of albu- 
minuria, often greatly aggravated ; and there can be no doubt that the 
morbid alteration in the blood gives rise, as has been observed by M. Blot 
and by Tyler Smith, to dangerous hemorrhage during or after labor. 
There is reason to believe, further, that it is in some way connected with 
the etiology of phlegmasia dolens, perimetritis, and possibly also with 
what is commonly called puerperal fever. 

In reference to the question of treatment, it is obvious that it must be 
of no small importance to ascertain, as early as possible after its devel- 
opment, the presence of the albumen. More especially is it of import- 
ance to be possessed of this information, in order that Ave may adopt such 
measures as may remove, or at least mitigate, the symptoms, before the 
period of labor arrives, at which experience teaches us to dread the oc- 
currence of convulsions, and the alarming results which spring from 
urnemic poisoning. In every case in which the symptoms point in that 
direction, including even the minor forms of oedema, it is well, as a mat- 
ter of routine in practice, to test the urine for albumen. Its presence 
may, doubtless, be discovered in many cases in which no other symp- 
toms exist, and the health of the woman is excellent. If so, the treat- 
ment will consist in careful regulation of the diet and of the functions, 
and in occasional observations of the urine, with the view of obtaining 
the earliest possible information of any morbid change. If the case is 
one wholly due to pressure, no serious symptoms whatever may be mani- 
fested, and the case may continue until the end of pregnancy, with the 
result of a happy labor and perfect recovery. Antiphlogistic treatment 
of any kind, more especially in such cases as are not observed until the 
disease has made some progress, must be resorted to with the greatest 
caution. For it must be remembered that the disease is one of debility, 

' It has also "been observed, as in a case brought nnder the notice of the writer hj 
Dr. J. D. Maclaren, that the disappearance of the albumen may coincide with the 
death of the child in utero. In the case in question, albuminuria appeared in the 
course of the sixth month and continued until the end of the eighth, when sudden 
and profuse diuresis set in, and the dropsy and the albumen disappeared in a few 
days. A week afterwards a dead child was born, which seemed from the state of 
putrefaction to have died just at the time the diuresis occurred. 



230 DISEASES OF PREGNANCY. 

and implies impoverishment of the blood, — a condition which calls more 
for a tonic treatment and a generous diet. Baths of various kinds are 
often useful, being at once grateful to the feelings of the patient and 
likely to promote the function of the skin. The use of diuretics has also 
been recommended ; but, if used, these agents should be employed cau- 
tiously, and in the mildest form. In a case which came under our ob- 
servation lately, a lady aged thirty-four, pregnant for the first time, had 
oedema of the ankles about the beginning of the sixth month, when a 
trace of albumen was discovered, — the urine being very scanty, high- 
colored, and loaded with lithates. The treatment adopted was the bitar- 
trate of potash, with Rochelle salts and benzoic acid, which kept the 
symptoms somewhat in abeyance, and manifestly improved the function 
of the kidney. The general health did not deteriorate, but the general 
dropsy increased, the quantity of albumen in the urine fluctuating con- 
siderably. All went on well, but, in the second stage of a tedious labor, 
the patient was seized with a most violent epileptiform attack. She was 
at once delivered with the forceps, made a good recovery, and in six 
weeks all trace of albumen had disappeared. In the above case, the 
benzoic acid was given, as recommended by Frerichs, with the vioAV of 
neutralizing the carbonate of ammonia which he believes to be formed 
in the blood by the decomposition of the retained urea. 

The significance of albuminuria during pregnancy has been viewed 
by some as of such serious import as to warrant the induction of prema- 
ture labor ; but to such an opinion, in so far as ordinary cases are con- 
cerned, we are unable to subscribe. So serious, however, is the probable 
issue of a case in which the quantity of albumen, the degree of oedema, 
and the general condition of the patient, tend to indicate the highest 
grade of severity in the symptoms, that we may be quite justified in 
entertaining gravely the propriety of such a course. But, in such cir- 
cumstances — and the remark applies equally to all cases in which the 
question of premature delivery may arise — it is proper not finally to re- 
solve upon such a step without, if possible, obtaining the sanction and 
approval of some colleague in whose opinion we may have confidence. 

Dr. Tyler Smith has pointed out, as an occasional accompaniment of 
pregnancy, the habitual occurrence of a large quantity of triple phosphate 
in the urine, which, under the circumstances, is of high specific gravity, 
and has an alkaline reaction. The same observer has noticed, further, 
that in some cases in which this phosphatic diathesis has been found to 
exist, fatty degeneration of the placenta had occurred in successive preg- 
nancies. The treatment of such cases consists in the use of the mineral 
acids, opiates, rest, and a nutritious regimen. 

A hypersecretion of the mucous membrane of the vagina constitutes a 
troublesome form of Leucorrhoea^ which is of frequent occurrence during 
pregnancy. A certain degree of this increase in the action of the glan- 
dular structures is to be looked upon as an ordinary accompaniment of 
pregnancy, due to the increased vascularity which is inseparable from 
gestation, and which manifests itself, as we have already seen, in a change 
in the color of the membrane. This, of course, requires no treatment 
beyond ordinary attention to cleanliness. But the quantity of the dis- 
charge is occasionally excessive, and varies greatly in its appearance, 



DROPSICAL AFFECTIONS. 231 

being in one case clear, in another milky, and in a third yellow and 
creamy like ordinary pus. Snch a condition is found occasionally to be 
associated with a growth of papillary projections on the surface of the 
membrane, which are sometimes as large as small peas, but more gene- 
rally very minute and spreading over the whole vaojina, giving to it a granu- 
lar appearance. This is what has been called Vaginitis Granulosa, an 
aifection accompanied with irritation and uneasiness, amounting in some 
instances to pretty severe pain, or, what is even worse, intolerable itching 
of the parts. The latter symptom may give occasion, even during sleep, 
to rubbing and scratching of the vulva, which may cause ultimately severe 
excoriation, and much sufifering. When circumstances render it probable 
that a specific cause exists, we must of course be on our guard against 
mistaking gonorrhoeal or syphilitic discharges for that which we are now 
considering; and, in cases where the diagnosis may be difficult, the pre- 
sence of condylomata and other unequivocal specific appearances will 
serve to remove all doubt. Generally, when the affection is due to preg- 
nancy, even the most profuse discharges rapidly disappear after delivery, 
and seldom attract any notice after the lochia has ceased to flow. Cases, 
however, occasionall}^ occur in which such a discharge, originally appear- 
ing; durins; pregnancv, lasts durinfi; the convalescence after labor, and 
ends in an obstinate and troublesome vaginal leucorrhoea. The treatment 
of this affection must necessarily be confined within certain limits, so that 
sometimes palliation is the most we can hope for. Cauterants, or strong 
injections, cannot be employed, lest they should induce premature labor, 
and even the simplest injections must, if used, be employed with the 
greatest possible caution, as it is well known that repeated injections, 
even of tepid water, will often suffice to induce uterine contractions. The 
resources at our command are, on this account, extremely limited, and in 
most cases must consist in cleanliness, warm baths, and emollient appli- 
cations. Medicated pessaries of various kinds, such as those which are 
made with tannin, or with alum and catechu, may also be used with safety 
and with every prospect of success. If there is much irritation or itching, 
the ingredients may be varied at will to meet these indications. 

General Dropsy, as symptomatic of, or coincident with puerperal albu- 
minuria, has already been fully noticed. There are other forms, how- 
ever, of dropsical disease which require attention, among which are 
Ascites, Dropsy of the Amnion, and the affection known as Hydrorrhoea, 
each of which calls for special remark. Ascites is a form of dropsy, 
familiar to the physician, and which is of frequent occurrence during 
pregnancy, and is probably due in most cases to the effects of mechanical 
pressure.. Sometimes it is developed at an early stage of gestation, in 
which case we should look upon the symptoms with considerable appre- 
hension, as experience has shown that the result is, not unfrequently, 
fatal to child or mother, or to both. It is rare, however, that it develops 
itself before the fifth month, and if the patient reaches the termination of 
the sixth month without ascites, it is unusual for the symptom to manifest 
itself for the first time after that period. A certain amount of effusion 
may take place within the peritoneal cavity without attracting any special 
attention, but as pregnancy advances, the amount of distension is out of 
all proportion to the stage which has been reached. Examination by the 



232 DISEASES OF PREGNANCY. 

usual process of palpation discloses the fact, in the same manner as under 
ordinary circumstances, but the site of the chief effusion is varied some- 
what in consequence of the presence of the distended uterus. On that 
account, fluctuation will be perceived most distinctly in the hypochondriac 
regions, and especially on the left side. The distension, as the case goes 
on, continues to increase to such an extent as to press injuriously upon 
the diaphragm and disturb the functions of the thoracic organs, while the 
amount of mechanical pressure is further shown by the projection of the 
umbilicus, which often takes the form of a protrusion, several inches in 
length, and as translucent as the scrotum in hydrocele. The abdominal 
walls become oedematous and pit on pressure, and if the case is still un- 
checked, the whole body becomes enormously swollen, while the blue 
lips, labored breathing, and rapid feeble pulse show how much the 
general functions are disturbed. In the course of such a case, the diag- 
nosis of pregnancy is seriously interfered with, and it may be impossible 
to make out the presence either of a solid body or a distended uterus ; 
and, besides, there is good reason to believe that, the uterus being 
separated to a greater or less extent from the abdominal walls, the sen- 
sation of quickening is deferred to an advanced period of gestation, or in 
some cases is never felt at all, although the child is alive and vigorous. 
The worst cases of all are those in which ascites is complicated with 
dropsy of the amnion, when the prognosis is very unfavorable. 

Caution must be exercised in the treatment of puerperal ascites, in so 
far as the use of drugs is concerned. It would appear, indeed, that not 
only is the free use of purgatives and diuretics prejudicial to the preg- 
nancy, and apt to bring on labor, but also that those agents have very 
little effect, in such cases, in checking the advance of the malady. We 
ought, however, always to try them before resorting to other measures ; 
but, should they fail, and the distension be such as to threaten the life of 
the woman, we have no choice left save between paracentesis and the 
induction of premature labor. In deciding between these two modes of 
procedure, we must be guided by the peculiarities of individual cases. 
The operation of paracentesis will be preferred in all such as may show 
a reasonable prospect of thus relieving the woman and allowing the preg- 
nancy to run its course, thereby saving both mother and child. It must 
be remembered, however, that the operation is very frequently succeeded 
by uterine contractions, so that the very measure which is adopted with 
a special view to the safety of the child, may possibly be the cause of 
its expulsion. In regard to the operation itself, it is clear that we can- 
not, without incurring the risk of wounding the gravid womb, operate in 
the ordinary situation ; so that another site must be selected. Scarpa 
operated in the left hypochonder, and Ollivier punctured on several 
occasions the protruding umbilicus with an ordinary lancet. Either of 
these sites might be adopted in cases where the operation had been, after 
due consideration, resolved upon, employing, however, for the removal 
of the fluid, the aspirator trocar, which is a great improvement on the 
old operation, and by means of which the risk is reduced to a minimum. 
We confess, for our part, that, seeing the frequency with which premature 
labor has followed spontaneously upon the operation of paracentesis, and 
the risk of peritonitis which the woman may run as a consequence of it, , 



DKOPSY OF THE AMNION. 233 

we look with more favor on the direct induction of premature labor as 
the proper measure to resort to in extreme cases. The nearer such a 
case approaches to the full term of gestation, the less need we hesitate 
in adopting this course ; but even when it involves the certain loss of the 
child, we believe that the most judicious course would be to adopt this, 
in preference to paracentesis. 

Dropsy of the Amnion. — There is, as has already been observed, a 
very great variety, consistently with quite normal gestation, in the 
quantity of the liquor amnii. It is, therefore, a matter of no little 
difficulty to determine the point at which the quantity becomes abnor- 
mal, but we shall probably not be wide of the truth if we put down the 
limit at from two to three pints ; so that, if the quantity should exceed 
this, the case may be held to come under the category of dropsy of the 
amnion. In extreme cases, from thirty to forty pints of fluid have 
escaped from the uterus. It was at one time generally believed that 
this form of dropsy was associated with some special morbid condition. 
It has been supposed, for example, to be due to inflammation of the 
amnion, constitutional syphilis, or to some diseased condition of the 
foetus ; but, although all these theories are possible, none of them have 
up to this period been demonstrated. It seldom has been observed before 
the fifth month, and is much more frequent in twin pregnancies. 

If any difficulty should be found in distinguishing between ascites and 
dropsy of the amnion, attention to the following points, which are laid 
down by Cazeaux as diagnostic, will generally enable us to make the 
distinction, if the cases are uncomplicated ; but it must not be forgotten 
that the two affections may coexist. In ascites, the urine is scanty and 
thick, and the lower limbs and genitals are oedematous. There is also 
fever and constant thirst. It is difficult, if not impossible, to recognize 
the outline of the uterus, and, in the course of our examination by pal- 
pation, distinct fluctuation is to be detected. In dropsy of the amnion, 
again, there is normal urine and little thirst. The lower limbs are often 
perfectly free from oedema, or, if it be present, it is so to a comparatively 
small extent. The rounded form of the distended uterus can generally 
be made out, but the fluctuation is very deep-seated and obscure. There 
is rarely any umbilical projection, and, if so, it is not transparent. The 
distension from dropsy of the amnion is sometimes enormous, and may 
threaten death by apnoea, by interfering with the function of the lungs. 
The natural relief which has, in such cases, followed upon spontaneous 
rupture of the membranes and the escape of the fluid, points very clearly 
to the only method of treatment upon which we can rely ; for, whatever 
may be the opinions entertained with reference to ascites, there can be 
no doubt that, in the afiection we are now considering, the only operative 
procedure applicable to cases where life is in danger is the induction of 
premature labor by rupture of the membranes. If the symptoms are 
not urgent, and the distension not excessive, careful attention to all the 
functions is the only mode of procedure which can be adopted, seeing 
that diuretics and purgatives are of no avail, and, besides, that the 
pregnancy may possibly come to a satisfactory termination. The result 
of this affection is very serious as regards the life of the child, but 
seldom implicates that of the mother, nor indeed, as a general rule, does 



234 DISEASES OF PREGNANCY. 

it seriously affect her health. The natural result is spontaneous prema- 
ture expulsion. 

Hydrorrlioea. — In this singular affection, which has also been called 
" false waters," a discharge of fluid takes place from the uterus, the 
amnionic sac remaining entire, and. the phenomenon being neither pre- 
ceded, nor necessarily followed, by uterine contractions. This occurs 
pretty frequently towards the end of pregnancy, and even although the 
quantity of fluid discharged may have been considerable, and have led 
to the idea that premature rupture of the membranes had occurred, 
labor, when it eventually occurs, is found to be accompanied in the first 
stage, as usual, by the formation of the '' bag of Avaters." The circum- 
stances under which the discharge occurs vary considerably. In some 
cases, it has an obvious connection with some powerful effort or acci- 
dental violence, while in others it comes on while the patient is at per- 
fect rest, or even during sleep. In one case the discharge may occur 
as a gush, in another it may escape guttatim ; or it may come on in 
either of these ways, and then, ceasing completely, may again and again 
return. The discharge is, in the first instance at least, attended by no 
pain, but in those cases in which the quantity is large, and the escape 
sudden, uterine contractions are apt to supervene, and premature delivery 
thus to ensue. 

The cause and source of a serous and usually colorless discharge which 
comes from the uterus during pregnancy, and is not the liquor amnii, are 
points of considerable interest, and to account for the phenomenon many 
theories have arisen. The only one, however, which it is necessary to 
mention here, as it is that which is almost universally accepted, is that 
the affection arises from a secretion which has its source in the inner 
surface of the uterus, and which, in proportion to its quantity, separates 
the coverings of the ovum from their uterine attachments. A pouch is 
thus formed between the decidua and the womb, Avhich gradually in- 
creases as more fluid becomes effused, until, making its way downwards 
towards the cervix, it finds a mode of exit, the fluid then escaping into 
the vagina and making its appearance externally. The treatment con- 
sists in enjoining strict rest in the horizontal posture in order to reduce 
this risk to a minimum ; and, if the gush has been sudden and the quan- 
tity large, it will also be proper, with the same object, to give an opiate 
in some form, to allay possible uterine excitement. The only practical 
mistake which might be made in such a case would arise from an error 
in diagnosis, for if we believed the discharge to indicate rupture of the 
membranes, we might, naturally enough, rather encourage the coming on 
of labor, believing that to be inevitable. 

Y. Disorders affecting Locomotion. — Attention has already been 
directed to the fact, now fully recognized, although long disputed, that a 
relaxation of the various pelvic articulations is an essential and physio- 
logical accompaniment of the pregnant state. This consists in a thicken- 
ing of the cartilaginous, and a softening and relaxation of the ligamentous 
structures surrounding the articulations in question. Along with this, 
there is a greater afflux of blood to the parts, and the more perfect struc- 
ture of the joints at these times — as shown, for example, in the increased 
secretion of synovial fluid — indicates that nature makes, as it were, an 



DISORDERS AFFECTING THE NERVOUS SYSTEM. 235 

attempt to establish here what exists in so many of the lower animals. 
The amount of motion which is thus permitted is, with the exception of 
the sacro-coccygeal joint, very trifling in normal cases, for were it other- 
wise the power of locomotion would be seriously interfered with. A 
certain number of rare instances have, however, been recorded, w^hich 
suffice to show that the articulations may be relaxed in an unusual degree, 
and thus a morbid condition ensue. Cases have, indeed, been examined 
by Morgagni, Hunter, and others, in which the separation between the 
pubic bones at the symphysis exceeded an inch, and in such cases great 
increase of the synovial secretion has been observed. The woman com- 
plains first of pain and uneasiness, which is aggravated on walking, or 
even by a trifling movement of the trunk. From being intolerable, loco- 
motion becomes impossible ; and, on careful examination, movement of 
the joint, attended with synovial crepitation, may sometimes be in- 
duced. Absolute rest should, as a matter of course, in all such cases, be 
strictly enjoined, for every movement either of the trunk or lower limbs 
will increase the morbid mobility, and by accustoming the joints to move, 
will render a cure, which cannot be looked for till after labor, vastly more 
tedious. After labor — the severity of which this affection will rather 
tend to mitigate — a similar course of treatment must be persevered in, 
to encourage the parts to resume their former condition. This will also 
be promoted by firm bandaging round the pelvis, so as to bring the ossa 
innominata more firmly together, and by the use, it may be, of some 
more rigid mechanical support, such as the steel girdle devised by Martin 
of Berlin. We have known, under such circumstances, locomotion ren- 
dered impossible for many months after delivery. Inflammation of the 
pelvic articulations is another occurrence which may call for attention, 
but cases of this affection are extremely rare. 

Locomotion, which is generally somewhat impeded in the last months 
of pregnancy, may be rendered extremel}^ painful, or at least very un- 
comfortable, by many of the aftections which we have been considering. 
Cases, for example, of relaxation of the abdominal walls in pluriparse 
and the anteversion of the w^omb which often accompanies it, are often 
attended with this inconvenience, which, under such circumstances, may 
be greatly relieved by the use of an abdominal bandage, so adjusted as 
to support the displaced womb. 

VI. Diso7\lers affecting the Nervous System. — The extent to which 
these may be multiplied by classification is almost illimitable. We shall 
here, however, confine our attention to a few only, leaving the more im- 
portant of them to be discussed in a future chapter, and passing over such 
as may be treated on general principles. The functions of each of the 
organs of special sense may be disturbed during pregnancy, and we may 
therefore meet with cases of deafness, aversion to certain odors or per- 
fumes which may previously have been deemed agreeable, dimness of 
vision, and even amaurosis, and, as regards the sense of taste, peculiari- 
ties are in this respect among the most familiar accompaniments of the 
pregnant state. Vertigo, flushings, syncope, and even itching of the 
skin, in the absence of any cutaneous irritation, must also be referred to 
the same class. Nor do the moral and intellectual faculties escape, in 
all cases, without suffering material disturbance. The subject of mental 



286 DISEASES OF PREGNANCY. 

alienation in the puerperal state will hereafter be more fully discussed, 
but there are minor degrees of aberration, both moral and intellectual, 
which do not amount to, or even approach insanity, but which are by no 
means of rare occurrence during gestation. Affection may, in this way, 
be replaced by unaccountable antipathy, a trusting disposition by jealousy, 
or a temper Avhich can scarcely be ruffled by wanton irritability. Amusing 
cases are even narrated, in which quite the contrary was the result, and 
in which whole households learned to hail with pleasure the pregnancy 
of the lady of the house, which was divulged to them by unwonted gen- 
tleness of manner and genial cheerfulness. " It is not uncommon," as 
Burns says, " to find women very desponding during pregnancy, and 
much alarmed concerning the issue of their confinement." This affection, 
closely resembling a similar state occasionally attendant upon disordered 
menstruation, amounts, when extreme, to melancholia, and seems, in both 
cases, to have its origin in an irritation which, starting from the uterus, 
operates reflexly through the nerves. Cheerful society, and careful 
attention to the diet and bowels, constitute, along with other similar 
measures, the only treatment proper to such a case. 

Pain, unconnected either with uterine contraction, or with inflam- 
mation, and referable to any one point in the abdomen, is an occurrence 
which occasionally, from its severity, calls for interference. In a certain 
number of such cases, there is, no doubt, as Scanzoni points out, an 
abnormal tenderness of the womb, which many have attributed to rheu- 
matism of that organ, during which either the whole womb, or a limited 
portion of it, may be the seat of very acute pain. When this is the seat 
of the pain, it is usually referred to the hypogastric region ; but there 
are many other instances in which pain of an equally acute character is 
experienced in other regions. Pain in the groins has thus been supposed 
to be caused by dragging on the round ligaments, which will be best 
relieved by an abdominal bandage and the horizontal posture. Pain in 
the lumbar region has, in like manner, although on what ground it is not 
clearly shown, been attributed to stretching of the broad ligaments. 
Pain and cramps in the thighs are most distressing accompaniments of 
pregnancy, and are due, in part to pressure on the sacral nerves, and in 
part to a reflex action, starting most likely from the uterus, but probably, 
in some instances, from the bowels. The abdominal walls also seem, in 
some cases, to be the seat of acute and almost constant pain. This 
occurs during the last months of pregnancy only, and' is generally con- 
fined to a limited space on the abdominal surface, — so that it is often 
difficult to convince the patient that it does not mark the seat of some 
severe local inflammation. All such painful affections as we have alluded 
to must be treated, during pregnancy, by the agency of measures which 
are merely palliative, and, in point of fact, palliation is the most that 
experience of such cases teaches us to anticipate. Warm baths in all 
cases, laxatives in the case of cramps, rest and local applications for the 
relief of the pain, are the only agents which, in most instances, can be 
employed ; for opiates and other anodynes are very generally contra- 
indicated, in so far as their internal administration is concerned. Among 
external applications may here be mentioned the soap and opium liniment, 
chloroform with tincture of aconite, and belladonna plasters. In the 



DISPLACEMENTS OF UTERUS. 237 

Tvorst cases, morphia may be resorted to, in the form of suppository or 
subcutaneous injection. The increased sensibility of the uterus is, in 
some of these cases, associated with particularly active foetal movements; 
and, very often, pain, which, has been relieved or deadened, is again 
awakened by a sudden movement, a sneeze, or a cough. 

YII. Displacements of the G-ravid Uterus. — Certain displacements or 
dislocations of the womb, which are of frequent occurrence in the unim- 
pregnated state, exist also, although more rarely, during pregnancy. 
The reason of the comparative infrequency is to be found in the fact 
that, while in all probability impregnation takes place in some instances 
of uterine displacement, the general effect of the subsequent development 
of the uterus in the course of pregnancy is to reduce the dislocation, and 
thus to avert the disastrous consequences of its persistence. As a rule, 
however, marked flexion or version of the unimpregnated organ is a 
barrier to pregnancy. 

In the affection known as Prolapsus or Procidentia^ conception may 
occur, and that even in cases where the uterus projects externally. But, 
while prolapsus frequently precedes impregnation, the details of some 
cases would seem to show that sometimes the prolapse succeeds the con- 
ception, the uterus descending instead of ascending as the development 
progresses, while the further growth of the organ takes place without its 
ever rising into the abdominal cavity. Examples of this have been re- 
corded by Portal, and by others whose statements we cannot permit 
ourselves to call in question. In some of these instances development 
has gone on entirely within the true pelvis. Up to a certain point, the 
uterus may no doubt occupy this situation without causing any symptoms 
of discomfort, and this in fact is what takes place, as we have seen in 
the first three months of normal pregnancy. But, should any mechani- 
cal impediment prevent, its further expansion in the direction of the abdo- 
men, or should any other cause induce its prolonged sojourn in the 
pelvis, the pressure which is exercised upon the bladder and rectum in- 
terferes seriously with their functions, and the case goes on, w^ith great 
suffering to the patient, until nature relieves herself by expelling prema- 
turely the contents of the womb. Those instances in which it is reported 
that pregnancy went on uninterruptedly, must, we presume, have been 
cases in which the cavity of the pelvis prevented very unusual dimen- 
sions. In some of them the uterus projected partially, but the most 
extraordinary of all, are those in which prolapsus has been complete, the 
gravid uterus lying in the form of a huge tumor between the thighs of 
the mother ; and, incredible though it may seem, it has been asserted 
that under such circumstances, pregnancy has reached its normal termi- 
nation without any special danger either to mother or child. The usual 
result is that abortion occurs before the end of the fifth month, as in 
cases narrated by Levret, Capuron, and others. The treatment will con- 
sist mainly in careful attention to the functions of the bladder and rectum, 
and in watching the progress of the case. When the prolapse has pre- 
ceded pregnancy, and circumstances point to the possibility of an occur- 
rence such as we are now considering, w^e should watch the case carefully 
as the period approaches at which the uterus should rise above the brim, 
and, if necessary, afford it some aid by careful manipulation, as was 



238 DISEASES OF PREGNANCY. 

done by Scanzoni in two cases. Should the organ appear externally, 
similar efforts should be made, failing which, it must be supported by an 
external bandage. But, so soon as dangerous symptoms manifest them- 
selves, or the bowels or bladder are so obstructed as to render defecation 
or micturition impossible, our course of procedure is clearly to act 
promptly, in such manner as may seem most judicious, with a view to 
the immediate expulsion of the contents of the uterus, for to allow such a 
pregnancy to continue would be to compromise the life of the mother 
without saving that of the child. 

Anteversion and Afiteflexion. — These forms of displacement are of rare 
occurrence during the early months of pregnancy. This is what an ob- 
servation of the anatomical relation which the organ bears to the pelvic 
walls would have led us to anticipate ; and, as Kiwisch has well observed, 
any such tendency which might exist is obviated further by pressure di- 
rected upwards against the fundus by distension of the bladder, and down- 
wards against the vaginal portion by repletion of the rectum. Cases have, 
however, been occasionally observed, giving rise to symptoms indicating 
obstruction to the action of the bowels and bladder. The digital exam- 
ination which such symptoms suggest reveals at once the nature of the 
case, the cervix being high in the hollow of the sacrum, while the fundus 
forms a rounded tumor in the roof of the vagina in the direction of the 
bladder. In such a case, the patient should be directed to lie on her back 
as much as possible ; and when the period arrives at which the uterus no 
longer finds accommodation within the pelvis, the fundus will rise upwards, 
and will thus spontaneously relieve any uneasiness to which the displace- 
ment may have given rise. This is the natural issue of such a case ; but 
it is quite possible that, in some instances, the dislocation maybe reduced 
by careful pressure upwards of the fundus by the finger, but this should 
onl}^ be attempted if the severity of the symptoms w^arrant any inter- 
ference. In the latter months of pregnancy, anteversion is of more fre- 
quent occurrence, and is then associated with the phenomenon of pendu- 
lous abdomen. It is observed almost exclusively in multiparoe, in whom 
the abdominal walls have been subjected to repeated distension, and in 
those, it is said, in whom the inclination of the pelvis is greater than 
usual. In direct proportion to the degree of displacement is the amount 
of pressure to which the bladder is subjected, and, consequently, the de- 
gree of discomfort to which it gives rise by impeding the flow of urine. 
In some instances, the abdominal wall not only projects forwards, but 
hangs downwards, and to those cases the term anteflexion is more appli- 
cable than anteversion, as the axis of the uterus is then bent in a greater 
or less degree. In extreme cases, the walls of the abdomen have been 
observed to hang down as far as the knees, but it seems likely that in most 
of these there is an actual hernia of the womb, owing to a separation of the 
recti muscles, between which it protrudes. This form of displacement 
may, as we shall have occasion hereafter to observe, cause difficulty in 
the process of parturition, by misdirecting the expulsive force ; but, in 
every case, the treatment is the same, and consists in an endeavor to raise 
the fundus by a bandage, supplying in this way the support which the 
abdominal wall should afford ; and, in addition, attending to the function 
of the bladder, remembering always that the greater the displacement of 



RETROVERSION AND RETROFLEXION. 239 

the womb, the greater is the corresponding elongation of the bladder. 
That organ, indeed, in some cases, loses all traces of a spheroidal form, 
and assumes the shape of an elongated pouch, which is bent over the 
symphysis, and which, therefore, can only be conveniently emptied by 
the use of a long elastic catheter. 

.Retroversion and Retroflexion of the gravid uterus are much more 
dangerous both to mother and child than displacements in the contrary 
direction. The distinction between the two varieties depends simply, as 
the names imply, upon whether the long axis of the uterus is straight or 
bent, and in each the fundus of the uterus occupies more or less com- 
pletely the recto-vaginal pouch of the peritoneum. AYe believe, however, 
that the distinction which is usually drawn between retroversion and retro- 
flexion, whether occurring in the unimpregnated state or during gestation, 
is more apparent than real. The majority of cases will be found in fact, 
on careful examination, to be neither exactly the one nor the other, but 
a condition intermediate between the two, in which the axis of the uterus 
is neither straight nor abruptly bent at the os internum like the neck of 
a retort, but forms the arc of a circle, the imaginary centre of which 
varies very greatly. 

As impregnation may take place of an ovum contained in a womb, the 
fundus of which is displaced backwards — although, probably, in a very 
limited number of cases — it is proper to notice here briefly the causes 
which have been assumed, and to a certain extent have been demonstrated, 
to lead originally to this displacement. It has been supposed, and we 
believe with good reason, that there is often an unusual mobility of the 
uterus in the direction which leads to the displacement we are now con- 
siderinor. This is due to a morbid relaxation and leno-thenino; of the round 
ligaments and vesico-uterine folds which thus admit in the first instance 
of a movement of the fundus backw^ards, encouraged by repletion of the 
bladder, and still more by over-distension, arising either from careless- 
ness or from any other cause. ^ The eftect of the combined action of 
these two causes is to induce a certain amount of displacement, which 
other circumstances may tend to aggravate or complete. While the 
uterus is in its normal position, it is impossible that distension of the 
rectum can cause retroversion, but so soon as the causes above detailed, 
or others to be mentioned presently, have acted so far as to press the 
fundus backwards towards the promontory of the sacrum, then this new 

1 Witli a view to the elucidation of the subject, Scanzoni made a series of most in- 
teresting observations both in the living and the dead. He found, in the first place, 
that distension of the bladder always caused a certain amount of displacement back- 
wards of the fundus. " We found," he says, " when we artificially filled the bladder 
in dead bodies, that the duplicatures of the jjeritoneum passing from the uterus to 
the bladder, stretched themselves in direct proportion to the distension of the bladder, 
so that when the bladder was filled and distended as far as possible, this stretching 
reached to such an extent that it was impossible, without considerable effort, to force 
the fundus of the uterus backwards for more than a few lines, as its attachment to 
the posterior wall of the bladder was much more firm than when that viscus was 
empty. A very different result ensued when we, in the first instance, cut the round 
ligaments and the peritoneal duplicatures above alluded to, and then filled the blad- 
der. In this case, by a moderate distension, the fundus uteri was strongly displaced 
backAvards, and the vaginal portion forwards, so that it depended upon our will, by 
the injection of a greater or less quantity of fluid into the bladder, to induce a higher 
or lower grade of retroversion." — Lehrbuch der Gehurtshilfe. 



240 



DISEASES OF PREGNANCY, 



force comes into play, the fecal masses, as they descend, gradually 
forcing the fundus further and further down into the pouch of Douglas, 
until a marked case of retroversion or retroflexion is the result. The 
other causes alluded to as auxiliary forces, are the downward pressure 
exercised by the abdominal viscera, and the existence of fibroid growths 
in the posterior uterine wall. At any stage, impregnation is possible, 
and it is easy to understand how, in such a case, a comparatively slight 
displacement may be converted into one in which the fundus fills the 
hollow of the sacrum, and may actually reach as far down as the coccyx. 
Before long, however, the limited space, within which, in this position of 
the uterus, the development of that organ goes on, becomes filled, and 
the pressure upon the bladder and rectum calls immediate attention to 
the case. An examination discloses the altered anatomical relations of 
the parts. The os and cervix will generally be found about the level of 
the sub-pubic angle, or somewhat above it ; while, behind this, and about 
the same level, a firm rounded tumor is felt, apparently occupying the 
recto- vaginal pouch, and pressing forwards the posterior wall of the vagina. 
(Fig. 97.) On examination by the rectum, — into which two fingers are 



Fm. 97. 




Eetroflexion of the Womb about the 16th week. (Schultze.) 



to be passed as high as possible, — the same tumor is felt through the an- 
terior wall, but in this method of observation, considerable difiiculty will 
often be experienced in passing the finger, owing to the great pressure to 
which the bowel is subjected. Backward displacement of the gravid 
womb has generally been observed in the third or fourth month of preg- 
nancy, but cases are recorded by Smellie, Bartlett, and others, in which 
it was observed as late as the fifth or even the seventh month. It is more 
than likely, however, that, in those instances, what Scanzoni describes as 



ACUTE RETROVERSION. 



241 



partial retroflexion was mistaken for complete dislocation of the organ. 
The partial retroflexion here referred to would be more accurately de- 
scribed as a peculiarity in the shape of the uterus, in consequence of 
which its posterior wall forms a tumor which, owing to some peculiarity 
in the position of the child, projects into the recto-vaginal pouch, and thus 
resembles an ordinary case. Assuming that this does actually take place, 
the occurrence is possible at a much more advanced period of pregnancy, 
when the development upwards of the remainder of the uterus would 
probably enable us, without much difficulty, to recognize the nature of 
the case. 

Of much more frequent occurrence than that which we have just 
described — and which we may call the chronic form — is acute retrover- 
sion in pregnancy. (Fig. 98.) This affection occurs suddenly, but it 
is most likely that there is a pre-existing minor degree of displacement, 

Fiff. 98. 




Retroversion about the 12th week. (Schultze.) 



which gives rise to a further and sudden change in the position of the 
womb sufficient to cause complete retroversion. Immediately upon the 
occurrence of this dislocation, or within a very short period, the woman 
complains of severe dragging pain, which is accompanied by a new sen- 
sation, as of a foreign body in the pelvis. This gives rise to painful and 
fruitless expulsive efforts, with increase of the pain around the entire 
pelvis, and great difficulty in emptying the bladder and the rectum. 
These symptoms are usually attended with faintness, nausea, and vomit- 
ing, and other general symptoms of even greater severity ; and, unless 
the reposition of the organ be speedily eflected, this state of matters gives 
rise to complete retention of urine and obstruction of the bowels, Avhich 
may, in their progress, result in rupture of the bladder, stercoraceous 
16 



242 DISEASES OF PREGNANCY. 

vomiting, ileus, and such symptoms as precede a fatal result. In many 
cases — perhaps in most of those in which the incarceration of the organ 
is prolonged — there is congestion and thickening of the uterine walls, 
and this may sometimes amount to actual inflammation of the organ, 
which becomes exquisitely tender, and thus aggravates greatly the suf- 
ferings of the patient. 

The natural termination of a case such as this involves great risk to 
the mother, and almost certain death to the child. For, although in its 
further development the womb may possibly take an upward direction 
and the symptoms be thus spontaneously relieved (and such cases are on 
record), the usual result unfortunately is, that the increase of the uterus 
gives rise to the more serious symptoms above detailed, which can only 
be relieved by arrest of development, or by expulsion of the foetus. 
Nothing can, therefore, be more obvious than the necessity which exists 
for prompt action in the way of treatment. Should the congestion of the 
womb be marked, benefit will be derived in the first instance from the 
use of warm baths and injections, and local or even general blood-letting ; 
and, when these measures have had time to act, attempts are then to be 
made to eff'ect the reposition of the organ, taking care, of course, in the 
first place, that the bladder and rectum have been thoroughly emptied. 

The woman having been placed in the ordinary midwifery position, 
with the nates projecting over the edge of the bed, or on her elbows and 
knees, the index and middle fingers, previously well oiled, are introduced 
into the rectum, so as to bear against the tumor, ^ and an effort is then to 
be made, by means of steady pressure in the axis of the brim, to push 
the fundus beyond the promontory of the sacrum. It will be observed, 
should it be found possible to displace the fundus to any extent, that the 
movement takes place not directly towards the promontory, but rather 
towards the sacro-iliac synchondrosis of either side ; and, as we cannot 
tell beforehand to which side it will incline, although the probabilities 
arc in favor of the right, we must, in the first instance, push directly up- 
wards. But, should the fundus obviously tend to move in the direction 
of one sacro-iliac joint in preference to the other, the direction of the 
pressure must then be altered, in order to accommodate it to the tendency 
thus exhibited. If the compression of the rectum is such as to prevent 
the introduction of the fingers to a proper height, Kiwisch suggests that 
we should substitute the handle of a silver spoon or of a sound for the 
finger. Should a first attempt at reposition fail, we may pause and en- 
deavor, by means of repeated injections, cold or warm, still further to 
reduce, if possible, the intumescence of the womb. The patient may 
then be brought fully under the influence of chloroform, and the attempt 
renewed in a difterent posture, when, in many instances, the dislocation 
will be happily reduced, the womb being occasionally restored to its 
normal position, as in the case of its inversion, with a snap or jerk. 
Should difficulty occur in the introduction of the finger into the rectum, 
it will be proper to make an attempt by the vagina, although in this case, 
as a little reflection will show, the attempt will be made at a greater 

1 Scanzoni recommends that the thumb of the same hand should be introduced into 
the vagina, mainly with the object of elevating the perineum, and thus allowing the 
examining fingers to pass higher. 



TREATMENT OF RETROVERSION. 243 

mechanical disadvantao;e than when the rectum is selected. Failino; all 
these methods, we may attempt to dislodge the fundus by the introduc- 
tion, as high as is possible, into the rectum of an elongated air-bag, such 
as those invented by Barnes for dilating the os and cervix in inducing 
premature labor. These bags have a long tube fitted at the end with a 
stopcock, and through this the injection, either of air or of water, causes 
a graduated pressure which acts continuously, and at the same time 
effectively, upon the displaced fundus, so as gradually to effect its re- 
pDsition. 

All attempts at reduction having failed, the best mode of procedure is 
to adopt only such measures as are necessary for the relief of the bladder 
and the rectum, so long as the symptoms are not so severe as to call for 
immediate action. But, should the emptying of the bladder become im- 
possible, or should any other symptom develop itself which may be held 
to imply that the life of the mother is in imminent danger, there then 
remains for us no resource but to imitate nature, and to induce, without 
delay, the premature expulsion of the foetus. Of the many methods by 
means of which, as Ave shall have occasion again to observe, it is possible 
to induce premature labor, that which is most applicable to the present 
case is the rupture of the membranes. For, the immediate eflPect, which 
is thus produced by the sudden evacuation of the liquor amnii, is to re- 
duce the diameter of the uterus, and thus to afford partial relief during 
the period which intervenes between the operation and the commencement 
of uterine action. It is, however, by no means an easy matter in every 
case to effect this rupture, more especially when the os is tilted up behind 
the symphysis, and is only reached with difficulty, and it may be found 
necessary on that account to introduce a catheter, with an opening at 
the extremity, through which a wire may be passed, and having reached 
the membranes, to thrust the wire through, and thus effect our purpose. 
But it may happen, unfortunately, that the os is displaced upwards to 
such an extent that it is impossible to reach it, or at least to pass any- 
thing through it, and in such circumstances we have no alternative, if the 
life of the mother is in obvious danger, but to puncture that portion of 
the uterine wall which lies lowest, and thus give vent to the amnionic 
fluid, and afford relief to the patient. It is of course safer, under such 
circumstances, to puncture from the vagina than from the rectum, but the 
latter operation has been successfully performed, effusion into the perito- 
neal cavity having been prevented, by leaving the canula in situ until 
the risk of further eftusion had passed. The uterus beino; thus relieved 
of its fluid contents, may now be replaced without much difficulty (unless 
adhesions should chance to have occurred) and then awakened expulsive 
effort will speedily relieve the organ of its solid contents. Where repo- 
sition of the uterus has been successfully effected, labor may go on with- 
out any further accident or hindrance, but in some few instances it would 
seem that a tendency to relapse remains. This must therefore be guarded 
against, by insisting upon strict rest on the side, and by the frequent use 
of the catheter and enemata, to prevent such mechanical pressure from 
the bladder and rectum as might encourage a recurrence of the displace- 
ment. 

Oblique displace mejits of the uterus have been insisted upon by some 



244 LABOR AND ITS PHENOMENA. 

writers as exercising an important influence on the progress of pregnancy. 
We know already that the long axis of the gravid uterus does not corre- 
spond with the middle line of the body. It is quite possible, therefore, 
that when this normal obliquity is exaggerated, the os may, for a time, 
be prevented from dilating by the altered axis of the expulsive force. 
Such displacements, however, seem to have had their origin in a great 
measure in the imagination of those who have sought to reduce the art 
of midwifery to a series of geometrical propositions, and are certainly 
not of sufficient practical importance to require more particular attention. 
In addition to the diseases of pregnancy which we have described, 
there are others, chiefly constitutional, which exist both during and after 
labor, the consideration of which we shall, therefore, in the mean time, 
defer. 



CHAPTEE XY. 

LABOR AND ITS PHENOMENA. 

Causes of Labor — Maturity : Antagonism heiween certain Groups of Uterine 
Fibres: Broivn-Sequard' s Theory: Labor coincident with the Tenth Menstrual 
Period. — Forces by which Delivery is Effected. : Nervi-7notor Functions of the 
Uterus : Effect of Emotional Causes : Reflex Function of the Spinal Cord : 
Peristaltic Action : Auxiliary Force in the Muscles of Expiration. 

Stages of Labor — Preparatory Stage. — First Stage : Labor Pains ; their effects 
on the Maternal Pulse and on the Uterine Souffle : False Pains : Mechanism 
of the Dilatation of the Os; thi Ba^ of Waters ; Effect of Longitr/dinal Fibres : 
Termination of First Stage m Tiupture of Membranes : Rigor : Show. — Second 
Stage: Change in Character of the Pains ; the '■'■ Caput Succedaneum ;" Action 
of Voluntary Muscles : Dilatation of the Perineum: Birth of the Head and 
Trunk. — Third Stage : ^''Dolores Cruenti :" Separation and Expulsion of the 
Placenta; Mechanism of this. 

The first point which, in considering the subject of Labor, attracts 
our notice, is one which has given rise to many interesting physiological 
speculations. We refer to the causes which lead to the occurrence- of 
delivery, in almost all cases in which the course of pregnancy is undis- 
turbed, at a certain fixed period, calculated from the assumed date of 
conception. In ancient times the idea prevailed that the foetus was 
itself the principal agent in effecting its birth, breaking the membranes, 
and opening up the womb in its efforts to reach the external world, after 
the same fashion as the chick when escaping from the thraldom of the 
egg. The advance of physiological science generally, and more espe- 
cially the discovery and demonstration of the contractility and muscular 
structure of the uterus, while they showed clearly enough how erroneous 
this opinion of the ancients was, did not disclose, and as yet have not 



CAUSES OF LABOR. 245 

clearly revealed, what is the cletermmmg cause of uterine contractions 
at the period alluded to. There exists, say some, a natural antagonism 
between the muscular fibres of the body of the uterus and those of the 
cervix ; and, so long as the obliteration of the cervix is not effected by 
the progress of development towards the end of gestation, the tonic con- 
traction of the fibres of the body is not suificient to overcome the resist- 
ance oftered by the cervix. But, as soon as the process of dilatation has 
entirely invaded the cervix, the fibres of the body for the first time pre- 
vail, and, the contractions assuming a rhythmical method of action, grad- 
ually increase in intensity until they result in real labor-pains. Others, 
and among them Dubois, recognizing the exact analogy which subsists, 
in regard to the distribution of muscular fibres and nerves, between the 
uterus and the other hollow viscera, and assuming that in the uterus, as 
in the rectum and bladder, contraction may be awakened by irritation of 
the cervix (to which alone, as we have already seen, the nerves of ani- 
mal life are supposed to have access), believe that in these facts the 
secret is revealed. They hold that complete obliteration of the cervix 
involves the highest grade of physiological development to which its 
fibres can attain, and that the sphincter fibres are then for the first time 
fully susceptible of external influences, communicated to them through 
cerebro-spinal nerves. And they conclude that, in this manner, the 
first excitation reaches the cervix, and thus contraction of the whole 
organ ensues. 

A most ingenious theor}^ has been founded by M. Brown-Sequard on 
the result of certain experiments which he performed by tying the 
trachea of pregnant animals, in whom he had previously destroyed the 
lower portion of the spinal cord. The immediate result of the apnoea 
thus artificially inducedy was the occurrence of uterine contractions, 
which disappeared on relaxing the ligature, and returned again on 
repeating the experiment. This is due, says the experimenter, to the 
contact of venous blood Avith the mjiiscular fibres, the irritability of 
which is highly exalted during pregnancy.. He explains the earliest 
uterine contractions on the same principle. The large size of the uterine 
sinuses ensures the presence in the substance of the uterus of a large 
quantity of venous blood, and so soon as the muscular fibre reaches, at 
the termination of pregnancy, its highest point both of irritability and 
of development, it becomes for the first time excited to contraction. 
The immediate result of this is to empty, in a great measure, the sinuses 
of blood ; but, so soon as the rhythmical relaxation occurs, the venous 
blood again gains access to the irritable fibres, and anew excites them to 
contraction. 

Whatever view we may be inclined to assume in reference to the cause 
of labor, there can be no doubt that it is coincident with the maturity of 
the foetus. Gradual relaxation of the anatomical connections between 
the uterus and the ovum, is another undoubted phenomenon which imme- 
diately precedes birth, and it was in this that Simpson believed the deter- 
mining cause to reside. And, finally, Dr. Tyler Smith has suggested, — 
and argues with great ability in favor of the theory, — that the cause of 
labor is to be found in the ovary. "It is allowed by all observers,'' 
says Dr. Smith, " that labor has a tendency to occur, and does occur, in 



246 LABOR AND ITS PHENOMENA. 

a great proportion of cases, in the fortieth week from the last menstru- 
ation ; and it is equally allowed that impregnation is generally eftected 
just after the catamenial period. It is also made out by the record of a 
considerable number of cases in which a single coitus occurred, that ges- 
tation lasts, on an average, about 275 days from the actual date of im- 
pregnation. These dates make the average duration of pregnancy ap- 
proach 280 days from the last catamenial period, and the occurrence of 
parturition is, on the average, very nearly a multiple of a single cata- 
menial period."^ We confess that the arguments which the author ad- 
vances in support of his theory seem, to us, in a great measure to war- 
rant the conclusion at which he has arrived ; but, while we admit that it 
is probable that a presiding influence springs from the ovary at the period 
of the natural menstrual molimen, we by no means wish to commit our- 
selves to the opinion that it is the sole cause. 

Whatever we may assume the cause of labor to be, the immediate 
effect of its operation is to rouse the latent energy of certain Forces, by 
means of whose active co-operation the delivery of the woman is effected. 
The prime force, to which the others are merely subsidiary, is, as is well 
known, the contraction of the muscular fibres of which the uterus is 
mainly composed. That these contractions are of very considerable 
power, is proved, not merely by the resultant of the force, as shown in 
the expulsion of the foetus, but also palpably to the senses by the con- 
traction which may be seen and felt through the abdominal walls, and by 
the eftect Avhich is produced on the hand when introduced into the uterine 
cavity. Dr. Matthews Duncan has computed this force as equivalent to 
a pressure of 3 lbs. on the square inch. 

In considering the nervi-motor functions of the uterus, we observe, 
in the first place, that volition exercises no direct influence whatever on 
the contraction of the uterine muscular fibre ; although, as we shall see, 
it presides over what will be afterwards described as the auxiliary forces. 
In cases of cerebral paralysis, and when the action of the will has been 
completely suspended by chloroform, we find that uterine contractions 
are quite undisturbed. Nay, stranger still, we know that, in some in- 
stances, contractions may occur after death, giving rise to post-mortem 
delivery. There are cases, at least, in which this phenomenon is due to 
actual contraction of the fibres ; but we must be careful to draw^ a dis- 
tinction between these and cases of expulsion, which have occurred some 
days after death, and which have been found to be due either to rigor 
mortis^ or to pressure from the development of gas in the process of 
putrefaction — a condition which gives rise to other strange phenomena 
familiar to the student of medical jurisprudence. 

' The following observation by Harvey has an interesting bearing on this point : 
" Unquestionably," he says, "the ordinary term of utero-gestation is that which we 
believe was kept in the womb of His mother by our Saviour Christ, of men the most 
perfect ; counting, viz., from the festival of the Annunciation, in the month of March, 
to the day of the blessed Nativity, which we celebrate in December. Prudent matrons, 
calculating after this rule, as long as they note the day of the month in which the 
catamenia usually appear, are rarely out of their reckoning ; but, after ten lunar 
months have elapsed, fall in labor, and reap the fruit of their womb the very day on 
which the catamenia would have appeared had impregnation not taken place." — 
" On Parturition." Sydenham Society Translation, 1846-47. 



INFLUENCE OF THE SPINAL CORD. 247 

Certain emotional causes produce an effect on the uterine contractions 
which it is not easy to account for. Few occurrences are more familiar 
to the accoucheur than the effect which his arrival frequently produces 
upon the progress of labor, by causing a complete temporary cessation 
of all uterine effort. On the other hand, sudden mental emotion of any 
kind may, by augmenting the force and frequency of the expulsive action, 
sometimes influence the progress of labor in a marked degree ; and this 
has been observed to occur upon the threat of using instruments, or upon 
the display of the forceps. Causes, then, which, being psychical, have 
their origin in the cerebrum, may act either by increasing or by arresting 
uterine eftbrt. 

The spinal cord exercises upon the uterus a very obvious and important 
influence. There is, in the first place, a direct or centric action, in which 
the motor nerves are excited by a communication starting from the 
nervous centre ; and it is in this Avay that ergot and other oxytocics act, 
being conveyed to the cord by the circulation, and there producing an 
effect which is transmitted to the uterus, where it takes the form of mus- 
cular action. In this manner, too, some diseased conditions of the blood 
produce an effect, as is well known, by acting on the cord, and giving 
rise to different varieties of puerperal eclampsia ; and in this way even 
plethora, or aneemia, may exercise an influence on the dynamic force of 
the womb. But of much greater importance, and of higher physiological 
interest, is the diastaltic, or reflex function of the cord, which chiefly 
presides over the motor functions of the uterus. One of the most familiar 
instances of this is the uterine contraction which ensues upon the irrita- 
tion of the nipple by the contact of the child. The impression is, in 
this case, conducted to the spinal centre, and being thence reflected to 
the uterus, forthwith acts upon its contractile fibres ; indeed, so constant 
is this occurrence, that it is admitted in practice as a valid reason for 
putting the child to the breast at an early period after delivery. A 
similar effect may be produced, although with less certainty, by an irri- 
tation of a similar kind starting from the stomach, rectum, or any other 
part of the alimentary canal ; from the ovary, or from any structure in 
the immediate vicinity of the uteras ; and, finally, from the direct irrita- 
tion of the organ itself, which may be effected in various ways, the most 
reliable of which is irritation of the os and cervix, or of the internal sur- 
face in the case of hemorrhage. The very extensive nervous sympathy 
which thus exists between the uterus and so many distant parts, shows 
pretty clearly that its nervous functions are, during pregnancy and the 
puerperal state, greatly increased. What is known, up to the present 
time, in reference to the uterine nerves, is by no means very satisfactory ; 
but the result of most modern investigations in regard to these nerves, 
which are only to be traced with the greatest difficulty, seems to confirm 
the view originally adopted by Dr. R. Lee, that they undergo, during 
pregnancy, considerable enlargement — an enlargement, however, which 
appears to have its seat mainl}^ in the neurilemma. This subject is one 
which has given rise to a deal of acrimonious discussion, and is still beset 
with difliculties which have only been partially overcome. It was stated 
in a former chapter that twigs of the sacral nerves, passing to the os and 
cervix, constitute the channel of communication between the cord and thQ 



248 LABOR AND ITS PHENOMENA. 

uterus, but that the rest of the nerves are derived from the ganglionic 
system. When, therefore, nervous force is reflected upon the uterus 
from the cord, it passes by the nerves in question, and reaches, in the 
first instance, the cervix and os. In this situation plexuses are found, to 
the formation of which the spinal and ganglionic systems contribute, and 
through these the force is transmitted to terminal fibres in the body of 
the organ, where it excites immediate and effective contraction. 

It is Avell known that the hollow viscera, which are supplied in whole 
or in part by the ganglionic nerves, contract, when irritated, after a 
fashion peculiar to such structures. The contraction, instead of being 
limited to the immediate vicinity of the point of irritation, is propagated 
in a definite direction in rhythmical waves, successive groups of fibres 
being thus excited so as to constitute the phenomenon commonly known 
as peristaltic action. The uterus forms no exception to this general law, 
and its peristaltic or ganglionic motor action was observed and described 
by Harvey and William Hunter, and by every physiologist of note since 
their day. The manner in which peristaltic uterine action occurs is, as 
Wigand has taught, in so far as the contractions of labor are concerned, 
as follows : The earliest contractions always take place at the neck, 
which grows tense. From this point, the vermicular action extends 
gradually upwards in the direction of the fundus, from whence it again 
returns towards the os, obvious mechanical advantages, of which we 
shall speak presently, being attendant upon this method of action. 
Uterine expulsive action is thus a composite force, which is partly 
diastaltic and partly peristaltic. Physiologists have sought, l)y many 
ingenious experiments on the lower animals, to ascertain w^hat is the pre- 
cise share which is to be attributed to the refl.ex function of the spinal 
cord in producing the phenomena of labor. These experiments have 
usually taken the form of section of the spinal cord at a certain level, or 
destruction of the lower part of the cord ; and it has been found that the 
latter procedure has produced the most decided effect in arresting uterine 
action. In most of these cases, however, it would seem that the peri- 
staltic action remained, and that there was still sufficient expulsive force 
left to effect delivery. In some cases, it would almost seem as if destruc- 
tion of the lower part of the cord put an end to all uterine action, but 
there are obvious sources of fallacy connected with such a method of in- 
vestigation which render it necessary to exercise great caution before 
coming to a positive conclusion. It is, indeed, a very difficult question, 
and one w^hich still remains for solution, whether or not, all connection 
with the nervous system of animal life being cut off", peristaltic contrac- 
tion remains possible ; for it must not be forgotten that, however 
thoroughly we may destroy the lower half of the spinal cord, there still 
remains, in the connections which subsist between the sym.pathetic system 
and the upper part of the cord, a possible, though circuitous route, 
through which the important influence of the cord may still, although 
more feebly, be exercised. 

In making the assertion that the will has no influence directly upon 
the contraction of the Avomb, we must not be understood as implying that 
the will exercises no influence on the progress of labor. For we shall 
see immediately that there is a stage of labor at which the voluntary 



STAGES OF LABOR. 249 

muscles are brought into play as an auxiliary force, and that the woman 
instinctively avails herself of their aid. The diaphragm and the abdomi- 
nal muscles are the chief agents of this new power, and everything there- 
fore which gives a fixed point for the efficient action of these muscles, 
indirectly gives great assistance in the progress of labor. It is this 
which causes a woman instinctively to arrest respiration, in order to 
admit of the efficient action of the diaphragm, and for the same reason 
she will eagerly employ the means which are afforded her, by towels 
tied to the bed-post, or footstools in the bed, to fix the trunk, so as to 
bring the whole power of the expiratory muscles into play. A minor 
degree of voluntary expulsive effort, which is in all respects similar, is 
that which attends difficult defecation. Haller attributed to the abdomi- 
nal muscles the chief share of the expulsive efforts in labor, but that this 
is obviously wrong is shown by the fact that in feeble women, in whom 
the voluntary muscular system is very poorly developed, the delive^ry is 
not only effected as easily as in others, but actually, in many instances, 
with greater ease ; and, moreover, complete amiesthesia, which has a 
most marked effect on the voluntary muscles, scarcely affects in any 
marked degree the progress of delivery. Another auxiliary force exists, 
in an advanced stage of labor, in the action of the muscles which consti- 
tute the floor of the pelvis, and in the contraction of the muscular fibres 
which enter into the composition of the vaginal walls. In the lower 
animals, as is well known, the comparatively feeble contractile efforts of 
the uterine cornua bring the young successively to the os uteri, when, 
powerful and violent propulsive efforts being awakened in the vagina, 
they are promptly expelled. In those animals, therefore, we may look 
upon the vagina rather than the uterus as the great organ of parturition. 
What occurs in the human species is precisely similar, only that here 
the vaginal contraction is subordinate to the uterine, while in rabbits and 
such like the converse is the case. That the vaginal expulsive force is 
by no means inconsiderable is shown by the manner in which the placenta 
is expelled, and still more by what involves a more powerful muscular 
effort — the expulsion of the head in cases of presentation of the breech. 
In regard to the share which is taken by the muscles at the floor of the 
pelvis, this, too, is in all probability considerable, and constitutes, no 
doubt, the " reflected force" of which Solayres de Renhac speaks in his 
admirable essay. 

The Stages of Labor. — Writers, in considering the physiological phe- 
nomena of labor, have uniformly adopted the plan of dividing its progress 
into various stages. Some have multiplied these stages to an extent 
which is absurd, as the subject is thus rendered more perplexing instead 
of being made easy of comprehension to the student. The familiar 
classification of Desormeaux, according to which labor is divided into 
three stages, is that which is adopted here. 

1st Stage. From the beginning of labor until complete dilatation of 
the OS uteri is effected. 

2d Stage. From full dilatation of the os till the birth of the child. 

3d Stage. The complete separation and expulsion of the placenta. 

In considering the First Stage of Labor, some little difficulty is expe- 
rienced in determinino; the exact moment from which labor is to be dated. 



250 LABOR AND ITS PHENOMENA. 

Long before symptoms of actual labor manifest themselves, certain pre- 
liminary processes are gone through, and to this some writers have with 
propriety attached the name of the Preparatory Stage. The falling 
down of the womb, which occurs in the last weeks of pregnancy, may be 
mentioned as perhaps the earliest of those changes. This, as has already 
been stated, is usually attended with a marked relief of such symptoms 
as arise from pressure upwards ; but these are often replaced by such as 
are the result of pressure in the contrary direction, so that dysuria and 
irritation of the lower bowel now become familiar symptoms. If an 
examination is made at this period, the head will be found to have 
descended in the pelvis, and the condition of the os characteristic of the 
stage of pregnancy will at the same time be disclosed. The ligaments 
also of the pelvis become more relaxed and elastic, and the articulations 
somewhat less firm. The first contractions of the womb at the com- 
mencement of labor are either painless, or accompanied with discomfort 
so slight as scarcely to attract the attention of the patient. Even thus 
early, however, the contractions may be perceived by the hand of the 
accoucheur, if he make an examination through the abdominal walls; 
and they are often accompanied with such an amount of pain as to lead 
a woman who has previously borne children to look for the speedy occur- 
rence of labor. ^ It is by no means a rare occurrence for this class of 
pains to recur again and again, night after night, keeping the patient in 
a constant state of expectancy and apprehension. Usually, however, 
the period soon arrives when the pains become more severe, and return 
at regular periodical intervals, when the contractions, as observed through 
the abdominal walls, will be found to be much firmer than those of the 
earlier period. 

A "Pain" in midwifery is used as synonymous with the expression 
" contraction," the one symptom depending directly upon the other. 
When, at the commencement of labor, the uterus is thrown into con- 
traction, the cervix being, as we have seen, first affected, and then the 
fundus, the muscular fibres, after remaining in a state of contraction for 
a brief period, relax, — as is usually the case in non-striated muscle, it 
being only exceptionally capable of sustained effort. During the whole 
period of a healthy labor, therefore, pain and pause alternate, the 
former being at first of short duration, and coming on at long intervals ; 
but, as the case progresses, the pains become longer and more severe 
and the pauses shorter and shorter, until, at the final effort, one pain 
succeeds another with such violence and rapidity that the periods of 
rest or pause are almost obliterated. When a pain comes on, it may in 
many cases be observed that the fundus, which is usually displaced to 
the right, moves toward the middle line, so as to bring the expulsive 
force to act in the direction in which it can be most efficiently employed. 
If we at this stage make a vaginal examination, we find, in primiparse, 
that the os and cervix are so far obliterated that the margin of the former 

' These early contractions are far from being the first which occur. Indeed, it is 
now admitted that painless nterine contractions occur from an early period of preg- 
nancy, and are often caused by the pressure of the hand through the abdominal 
walls, when they may be recognized with ease, and constitute, indeed, under such 
circumstances, special evidence as to the tumor being uterine. No other tumor con- 
tracts under the hand in a similar manner. 



FIRST STAGE. 251 

is a thin, circular, and almost membranous ring, which represents that 
portion of the uterus. Against this apparently unyielding ring, the 
membranes are firmly pressed during the continuance of a pain ; and, as 
the amnionic fluid necessarily takes the direction in which there is least 
resistance, it is found that at this moment the difficulty of reaching the 
presenting part is increased by the augmentation in the quantity of the 
imposed stratum of liquid, and by the tension to which this gives rise. 
Soon, however, the rigid margin becomes softer and more tumid, a con- 
dition which, in pluriparge, exists from the first, and the os yields slowly 
under the influence of successive pains, so that we are able during the 
intervals of perfect rest to hook the finger into the os, and to feel dis- 
tinctly the presenting part. 

It is interesting to observe the eff'ect which is produced on the mother's 
pulse by the occurrence of a pain. If, placing a finger upon it, we note, 
during an interval of rest, the number of beats, and continue the obser- 
vation, we shall find that, with the commencement of the pain, its fre- 
quency is increased, and that, continuing to rise, it attains its maximum 
along with the pain; while with its subsidence, the pulse falls, and on 
its complete cessation is found to have returned to its original rate. This 
observation, as Hohl points out, may be usefully employed as a test to 
gauge the efficiency of the pains, for the more marked and rhythmical 
this variation of the pulse, the more effective is the pain which it at once 
accompanies and indicates. " "When, however," he says, " the rapidity 
of the beats subsides before approaching the maximum, the pain is too 
weak ; or Avhen the rapidity rises by sudden starts, the pain is a hur- 
ried one, and in either case its effect will be imperfect." He assumes 
that, in an efficient pain of average duration, the increase and diminution 
of the pulse for each quarter of a minute may be put down as follows : — 

18. 18. 20. 22: 24. 24. 22. 18. 

It would thus appear that the frequency of the maternal pulse attains 
its maximum during the first half of the second minute ; but it must be 
understood, in making observations based upon this, that it applies to 
average pains only, and that towards the termination of labor, when the 
systemic excitement is intense, the pulse from that cause is often so 
accelerated that any observation of the kind is impossible. If ausculta- 
tion be practised during the pains, we often find that the foetal pulsations 
are somewhat accelerated, but the effect of a pain tends rather to obstruct 
than to facilitate the observation of the foetal heart. The uterine souffle, 
however, undergoes, almost invariably, marked modifications. The situa- 
tion having been ascertained at which that sound may most distinctly be 
made out, auscultation is sustained during the continuance of a pain, or 
of a succession of pains, when the following modifications are observed. 
The approach of a pain is heralded by a rushing sound, which may indi- 
cate muscular action, movement of the amnionic fluid, or movement of 
the child. Along with this, there is a marked increase in the distinctness 
of the souffle, which is raised in tone and in pitch, and may even become 
vibrating or musical. Up to a certain point this increases in intensity ; 
but, as the pain approaches its acme, the sound becomes as it were more 
and more distant, and then — when the moment of greatest contraction is 



252 LABOR AND ITS PHENOMENA. 

attained^ — very faint, or altogether inaudible ; while, as the pain goes off, 
it passes again through those changes in an inverted order, until the tone 
proper to the period of rest is restored. 

We must be prepared in every case for the occurrence of what are 
called False Pains, in which, although there may be uterine contraction, 
it is not of a proper kind. The pain in such cases may be severe enough, 
but it is spasmodic and variable in character, and, instead of beginning 
in the cervix and extending upwards, as in a true labor pain, it commences 
usually in the fundus or body, and is attended with no symptoms indi- 
cating progress towards delivery. These pains, which are referred to 
the region of the fundus, and not to the loins as in normal labor, probably 
depend upon some irritation, having its origin, in a large proportion of 
cases, in some derangement of the digestive system. The leading cha- 
racteristics, then, of what, for the sake of distinction, we call True Labor 
Pains, are uterine contractions, which commence at the os, and thereby 
prevent, by the constriction of its sphincter fibres, the descent of the 
umbilical cord, or of such parts of the foetus as might impede delivery. 
These contractions are accompanied with pains, which may begin in front 
and pass round to the sacrum, but which are generally referred mainly 
to the lumbar and sacral regions. 

From an early stage of labor, the tissues are prepared for their new 
function by a profuse secretion from the vagina and cervix of a thick 
colorless mucus, while the parts from Avhich it flows become softer and 
more cushiony. This discharge, which is occasionally tinged with blood, 
is frequently mixed with little semi-solid albuminous masses, and is very 
obviously provided by nature for the purpose of lubricating the parts, and 
thus facilitating the progress of the foetus along the canal through which 
it has to pass. Upon the quantity of this secretion, the ease of the labor 
undoubtedly depends in no small degree ; not by its lubricating action 
alone, but because its appearance involves a softening and general pre- 
paredness of the tissues, dependent upon the unloading of the congested 
vessels. There is no sign upon w"hich, as indicating the probable dura- 
tion of a case of labor, the accoucheur looks with more confidence than 
this ; and from a copious secretion and relaxed condition of the parts, he 
augurs an easy and speedy labor, while from a dry, constricted, and rigid 
vagina, he learns that in all probability a lingering, exhausting labor will 
lead to a tardy delivery. 

The phenomenon which essentially attaches to that stage of labor Avhich 
we are now considering is the dilatation of the os and cervix, and it has, 
on that account, been called by some the " stage of dilatation." From 
what has already been said with reference to the nature of uterine con- 
traction, it is evident that the effect of each individual pain, when efficient, 
must be to contribute to the opening or dilatation of the os. And, fur- 
ther, it must be obvious that, while the membranes are intact, the pre- 
senting part of the child can play but a trifling part in the mechanism of 
distension. The more attention we give to this subject, the more mast 
we admire the admirable adaptation of means to an end which nature 
has in this instance adopted, where the object is, as we must remember, 
not only the expulsion of a solid body through a certain channel, the in- 
tegrity of which must be preserved, but its expulsion in such a way as 



DILATATION OF OS. 253 

may least endanger its independent vitality. It is for that purpose, doubt- 
less, that the membranes are thus preserved. 

The first efficient contractions having probably resulted in an opening 
of the cervix to a trifling extent, and the tissues being sufficiently relaxed 
to admit of satisfactory progress, we are enabled to trace the process of 
dilatation through all its subsequent stages. When the os has so far 
yielded, the membranes, which are here separated from their uterine at- 
tachment, commence to protrude in the form, first of a watch glass, and 
then of the extremity of a pouch or bag, which has been termed the "bag 
of waters." Following the operation of a very obvious law already 
alluded to, this phenomenon implies, primarily, an attempt, consequent 
on the uterine contraction, on the part of the waters, to escape in the 
direction in which resistance is least. The special function, however, of 
this bag is to effect the further dilatation of the os, and we can conceive 
no means which could be more admirably adapted to this object than the 
graduated fluid pressure which is thus brought to bear upon the os equally 
in its whole circumference. It constitutes, in fact, in its action during a 
pain, a hydrodynamic force acting at once safely and powerfully upon 
the Avhole of the os. But another effect of this action is of even higher 
physiological interest, for in it we observe a means by which the head of 
the child is protected from all pressure during the first stage. If we 
make an examination, in the interval between the pains, when the os is 
moderately dilated, we can generally feel quite distinctly, through the 
membranes, the head, or other presenting part, and are able to distinguish, 
for example, the different sutures and fontanelles. A pain then comes 
on ; but, instead of the head being driven downw^ards against the still 
rigid OS, it recedes, and the bag of waters takes its place in effecting that 
dilatation which, when premature rupture of the membranes occurs, must 
of necessity be performed by the head itself. And the result, when that 
occurs too early, is, as every one knows, protracted labor and increased 
risk to the child. As the termination of the first stage approaches, the 
protrusion of the bag of the membranes becomes more and more marked ; 
and as, at the same time, the pains usually become more violent, it often 
excites our astonishment that rupture is so long delayed, and we look for 
its occurrence at every pain. The bag by this time forms in the vagina 
a tumor of considerable size, and, in some cases, where the membranes 
are unusually resistant, this tumor completely fills the vagina, and even 
protrudes externally, — a condition which, as we shall have occasion after- 
wards to notice, constitutes a serious impediment to delivery. 

This purely mechanical force, although we believe it to be the chief, 
is certainly not the only one which is brought to bear in the course of the 
process of dilatation. For we cannot doubt that it is powerfully assisted 
by the contraction of the longitudinal fibres of the uterus, which tend to 
drag the margin of the os upwards at the same time that the fluid is being- 
forced downwards, and some have gone so far as to believe that it is 
mainly by their agency that the dilatation of the os is effected. Without 
crediting this latter assumption, we may look upon these longitudinal 
fibres as antagonistic, in their action, to the circular fibres which sur- 
round the OS so as to form a sort of sphincter. While we admit such an 
action as this, we must not overlook the fact, which has already been 



254 LABOR AND ITS PHENOMENA. 

demonstra^od, that the arrangement of the uterine muscular fibres is ex- 
tremely irregular. Were the number of longitudinal fibres which are 
directed towards the cervix greater, and were the arrangement of a circular 
sphincter more distinct, we might more readily accept this as the main 
dilating power ; but knowing what we do of the irregularity of these 
structures, we can only accept of it as a subsidiary force. In cases in 
which rupture of the membranes precedes dilatation of the os, the me- 
chanism of the act is somewhat diiferent, as in that case the walls of the 
uterus are brought to bear directly against the surface of the foetus, the 
head being forced, at each pain, against the circumference of the os, which, 
at some risk, and by a slower process, is thereby dilated. 

A very frequent occurrence on the termination of the first sta^e is a 
Rigor. This is a symptom which might vecj naturally excite alarm in 
the mind of a young practitioner, more especially ag it is sometimas so 
violent as to shake the bed on which the patient lies. It is, however, 
attended with no diminution but, on the contrary, by an increase of tem- 
perature, nor is it in any way affected by the application of warmth to 
the surface. This rigor is in fact a phenomenon purely physiological, 
and is similar to what is observed upon dilatation of the other sphincters 
of the body, a familiar example of which is afforded in the shudder which 
sometimes passes over the body during the act of micturition. 

Another familiar symptom is the slight discharge of blood w^hich about 
this time commonly occurs, the ordinary discharge being mixed, or at 
least streaked, with blood which proceeds from the rupture of small 
vessels in the os consequent upon its extreme distension. This is what 
midwives call a " Show." But the crowning act of the first stage is 
rupture of the membranes, which usually occurs at the height of a pain, 
and is accompanied with a sudden gush of liquor amnii, usually propelled 
with considerable force, and w^ith a sound which is often quite audible to 
the attendants. If this gash of water coincides, as it usually does, with 
complete dilatation of the os, it marks the termination of the first stage. 
Complete dilatation of the os must not be held at this stage to imply that 
obliteration of it which converts the parturient canal from the fundus 
uteri to the ostium vaginae into a continuous tube, as shown in the figure 
which follows, for it is not till the second stage has well advanced that 
such an amount of dilatation is effected. Fall dilatation at the termination 
of the first stage means merely such as will permit of the further progress 
of the head. 

The pains which accompany the first stage are of a character peculiar 
to themselves, and are of a more teasing, worrying, and wearing nature 
than the more severe agony which subsequently occurs. The chief an- 
noyance that the woman feels is from the fact that she fancies she is 
making no progress, and the stage is, therefore, often to her wearisome 
and tedious in the extreme. She questions her attendants again and 
again as to the probable duration of her suffering, but this is a point in 
regard to which we should be specially cautious in risking an opinion. 
Nothing is so likely to mislead us in this respect as the apparent intensity 
of the pain. For not only do certain Avomen bear pain bett 3r than others, 
but the same degree of uterine contraction may, in individuals of different 
nervous susceptibility, produce a very different amount of actual suffering. 



DURATION OF FIRST STAGE. 



255 



The intensity of the pain, therefore, is not always in proportion to the 
degree of contraction, and still less is it to be held as a safe indication 
of its efficacy. 



Fis. 99. 




Parturient Caual completed l)y the Obliteration of the Os aud Cervix. 



The duration of the first stage varies exceedingly, both in primiparae, 
and in those who have had several children. Considerable difficulty in 
determining this point arises also from the impossibility of fixing the 
exact period at which this stage may be supposed to commence. As- 
suming it, however, to date from the first sensible contractions, we may 
assume that, Avith ordinary pains, and a normal condition of the parts, 
full dilatation may be effected on an average in about six hours, the time 
in primiparoe being somcAvhat longer than in other women ; but the stage 
may nevertheless last for one hour only, or for twenty-four, without the 
occurrence, in either case, of a single symptom to cause the least anxiety. 
It has been frequently observed by the most experienced accoucheurs 
that, in those instances in which the first stage is tedious, the subsequent 
stages proceed with unusual rapidity. Sometimes, cases in which there 
is unusual rigidity of the neck of the womb come to an unexpected and 
rapid termination in consequence either of rupture of tissue or of sudden 
relaxation of the sphincter fibres. 



256 LABOR AND ITS PHENOMENA. 

TJie Second Stage. — Upon the termination of the first stage, the uterus 
gathers itself for further effort by tonic contraction around the body of 
the child. The pains now undergo a remarkable change. Not only do 
they continue to increase in frequency, duration, and severity, but the 
whole character of the pain is altered. The woman has now a conscious- 
ness of a solid body which has to be expelled, and she therefore brings 
to bear upon it, half involuntarily, the action of all such voluntary muscles 
as she has at command. The contractions, at the same time, although 
actually more severe, are much more easily borne, — and apparently for 
this reason, that the woman is now conscious that progress is being 
made. These are well termed " bearing down," or expulsive pains, and 
this stage has therefore been described by some writers as the Propul- 
sive stage of labor. Considerable resistance may still be offered by the 
OS uteri, when rigid, to the advance of the head, and, if so, an oedematous 
swelling, which is limited in its circumference by the pressure of the os, 
forms on the presenting portion of the scalp, and may attain a considera- 
ble development. This is called the ^' caput succedaneum.^^ The ante- 
rior lip of the OS may also become oedematous, in consequence of pressure 
between the advancing head and the pubis : but, as a rule, it slips up 
after a time, and the canal then becomes, for the first time, a continuous 
one. But it is usually not until the head has escaped from the embrace 
of the OS, that the caput succedaneum forms, its size depending upon the 
degree of resistance wdiich is offered by the perineum, and by the other 
tissues surrounding the ostium vaginse. This swelling is always more 
marked in primiparge, and its exact situation on the scalp depends upon 
the extent to which the movement of rotation, to be afterwards described, 
has taken place. We now find that when the head is forced down during 
a pain, the sutures overlap each other considerably, their situation being 
then indicated by a furrowed or wrinkled line on the scalp. The whole 
auxiliary force, formerly alluded to as residing in the abdominal and 
other muscles of expiration, now comes into play, and it is a wise provi- 
sion of nature that, however low the head may stand in the pelvis, this 
seldom occurs until the dilatation of the os is complete ; for we may be 
pretty sure that were it otherwise, laceration would be of more frequent 
occurrence. Every means which may in this way strengthen the expul- 
sive effort is instinctively adopted. The respiration is arrested, the limbs 
are fixed, the cry ceases, and the woman presents the appearance of one 
who is undergoing a powerful struggle of muscular strength and energy. 
It is usually during the height of the pain only that the cry ceases alto- 
gether, but even in women who make more noise than usual, the charac- 
ter of the cry is completely altered, and is clearly indicative of violent 
effort ; indeed, so characteristic is this, that it is narrated of an old 
French accoucheur, that when he went to sleep while attending an 
accouchement, he was always roused from his slumbers by the altered 
nature of the patient's voice to a sense of his impending duties. The 
muscles of the floor of the pelvis, and the muscular fibres which enter 
into the composition of the vagina, aid still further the propulsive efforts; 
while the expiratory muscles are stimulated to redoubled energy, by a 
reflex action starting from the sensory nerves of the vagina. There is 
every reason to believe, moreover, that the pressure exercised upon the 



DISTENSION OF THE PERINEUM, 



257 



uterus by the abdominal muscles, constantly increasing as the over-dis- 
tension of their fibres is reduced, is a supplementary cause of the propul- 
sive vigor of the uterus, which is, by the contraction of the former, more 
actively stimulated. 

Violent, however, as the propulsive efforts are, they are not attended 
with that danger to the integrity of the parts which might, perhaps, have 
been expected ; for so soon as they reach such a point as would seem to 
endanger the latter, "the short gasp or cry is," as Tyler Smith says, 
" exchanged for a cry which dilates the glottis, and the pain and contrac- 
tion subside. This cry is a motor action, excited by the emotion of pain, 
and instantly relieves the uterus of all extra-uterine pressure. Thus the 
glottis may be compared to a safety-valve, which is thrown open by emo- 
tion whenever the pressure becomes more than can be borne with safety." 
The presenting part, which now approaches the outlet of the vagina, 
soon presses directly upon the perineum, which bulges downwards; and, 
at the height of a pain, when this bulging is most marked, that part of 
the child which is to be first born, presents itself at the vulva. This is 
admirably shown in the accompanying engraving. (Fig. 100.) The 

Fi-. 100. 




Distension of the Perineum. (After Hunter.) 

rectum now becomes flattened, and its sphincter dilated, so that any fecal 
matter which may have been lodging there is unavoidably expelled. The 
margins of the anus being dragged apart, the anterior wall of the rectum 
is exposed, and thus becomes, as it were, a temporary portion of the 
perineum, as is shown in the figure, while the perineum itself becomes 
more and more distended, for which modification, indeed, its structure, 
and the nature of the attachments of its muscles, admirably adapt it. 
The hemorrhoidal veins are frequently much distended, and the dilata- 
tion of the perineum goes on both longitudinally and transversely, in a 
progressive manner, proportionally to the violence of each pain, with 
which the perineum projects as far as is safe ; while, on the subsidence 
of the pain, the elasticity of the perineal structures causes the head again 
to recede. 
17 



258 LABOR AND ITS PHENOMENA. 

Alternately advancing and retiring in this way, but always gaining 
ground, the head ultimately passes the distended aperture in a direction 
forwards, under the pubic arch, the perineum now presenting the appear- 
ance of a thickened membrane. In many cases, the head is arrested by 
the cessation of a pain, just at the moment when its greatest diameter is 
encircled by the circumference of the vulva, but it does not now recede. 
This has been called the stage of " crowning," and may be looked upon 
as favorable to the integrity of the soft tissues. A final pain now brings 
the presenting part into the world, and this period, which immediately 
precedes delivery, is that at which the suffering of the woman reaches 
its highest pitch, — sometimes amounting to frenzy, — and it is wisely and 
mercifully provided, in some codes of jurisprudence, that any act of 
violence committed at this moment is viewed with special leniency. 
Upon the birth of the head, the woman enjoys a brief interval of relief, 
but the pains soon return, and complete the delivery of the remainder of 
the child. The external parts, which have become contracted around 
the neck upon the passage of the head, are again dilated, and the 
shoulders are expelled. It will be found, however, that it is not inva- 
riably the anterior shoulder, as is stated in many works, which is first 
expelled ; for, in a very considerable number of instances, that shoulder 
which lies towards the perineum takes precedence. in its passage into the 
world. During this stage, a slight amount of laceration generally takes 
place in the direction of the distended perineum, and in primiparse, 
indeed, the fourchette seldom, if ever, escapes. The remainder of the 
infant then passes, and with it a gush of blood and the rest of the 
amnionic fluid. The uterus now contracts firmly on the placenta, and 
may be felt, as a hard globe, above the symphysis ; while the abdominal 
walls become flaccid, and the mother experiences a feeling of calm and 
perfect rest, which yield to her, from the comparison, a sensation of 
delicious repose. 

The TJiird Stage. — The final contractions of the second stage are 
sometimes so violent as to expel the placenta along with the child. 
This, however, is an unusual occurrence, and what generally takes 
place, when the case is absolutely left to nature, is as follows: The 
child, on its birth, remains connected with the placenta by means of the 
cord, which, for a time, continues to pulsate. The latter being divided 
in the manner to be described in the following chapter, the woman re- 
mains at perfect rest for an interval of about ten minutes or a quarter of 
an hour, on the average. The uterus then begins spontaneously to con- 
tract upon the placenta, the expulsion of which organ constitutes the 
Third Stage of labor. The pains of this stage, although of the same 
expulsive nature as those which preceded it, are comparatively trifling, 
and are accompanied with more or less of the blood which has escaped 
from the ruptured utero-placental vessels. They were, on this account, 
designated by the older writers dolores cruenti. A few of these con- 
tractions generally suffice to eff'ect the complete separation of the pla- 
centa and its propulsion into the vagina, but the feeble contractile power 
of the latter often renders it necessary to give some assistance in the 
delivery. The placenta and the adhering membranes being expelled, 
this final act terminates the labor. 



THE THIRD STAGE. 



259 



The description originally given by Baudelocque as to the mechanism 
of the birth of the placenta has been adopted by almost all modern 
authors, and the demonstration which has lately been given of it by 
Schultze, in his admirable Waiidtafeln (see Fig. 101), is in every 
respect confirmatory of the views of the great French obstetrician. The 
description given by them of the process is, that the placenta passes 
through the vagina inverted, with its foetal or amnionic surface turned 
outwards, an assertion which, in so far as the natural process is con- 
cerned, is quite incorrect. That the placenta passes, in a large number 
of cases, in the manner shoAvn in Fig. 101, is probably true enough, but 
the reason is, that the practice of pulling on the cord is resorted to with 
too great frequency in general practice. For if we believe that the 
normal process is thus represented, it will seem rational enough, when 
delay occurs, to pull gently towards the ostium vaginae that portion 
which nature intends should first be born. In cases, however, which 



Fi?. 101. 



Fi^. 102. 





Alleged Inversion of Placenta in the 
Third Staije. 



Normal Position of the Placenta in 
the Third Stasfe. 



are left entirely to nature, it will almost invariably be found that it is 
not the foetal surface but the edge of the placenta which presents, and it 
is this part, overlapped it may be by the membranes, which will be found 
to pass first both into the vagina and through the vulva. This is the 
description which has been given by Lemser, Cazeaux, and some others, 
and, more recently. Dr. Matthews Duncan has, in a paper distinguished 
by his usual ability, put the matter in a perfectly clear light. In his 
drawing (Fig. 102), which we here reproduce slightly modified, the 
placenta is shown folded upon itself, Avith the detached uterine surface 
turned towards the observer, " but the folds are," as he observes, " ac- 



260 MANAGEMENT OF NATURAL LABOR. 

cording to the length of the passage, not transverse to it, as inversion or 
presentation of the foetal surface imply." We are fully persuaded that 
the observation of half a dozen cases, in which no interference with the 
cord is permitted, will convince any one of the truth of these assertions. 
It will be shown presently that they involve some points of practical 
importance. 

The uterus may now be felt behind the pubes firmly contracted, and 
on the maintenance of this tonic contraction depends mainly the safety 
of the woman from the dangers of post-partum hemorrhage. It some- 
times occurs, however, that the rhythmical efforts persist, when the 
womb may be felt in alternate stages of relaxation and contraction with- 
out necessarily any particular loss of blood. 



CHAPTEE Xyi. 

MANAGEMENT OF NATURAL LABOR. 

Duties of the Accoucheur . — Preliminary Arrayigements. — False Pains and their 
Treatment. — Armamentarium of the Accoucheur. — Position of the Woman 
during Labor. — Digital Examination : Points to he Examined. — The Patient 
not to take to led during the First Stage. — Preparation of the Bed, etc. — Ab- 
dominal Muscles to be called into play during the Second Stage. — Management 
of the Anterior Lip of the Os. — Obstacles arising from Rigid Os ; and from 
non-rupture of Membranes. — Use of Stethoscope. — Views regarding Support 
of Perineum. — Treatment if Laceration is threatened. — Causes of Laceration. 
Birth of the Head. — Passage of the Trunk. — Ireatment of Suspended Anima- 
tion in the Child. — Ligature of the Cord. — Management of the Third Stage: 
Crede's Method. — Application of Abdominal Bandage. — Treatment of the 
Woman after Delivery. 

Having in the last chapter fully considered the various phenomena 
attendant upon natural labor, the subject of the duties of the accoucheur 
remains for our consideration. It is fortunate that, in a very large pro- 
portion of all cases, the various stages of labor are effected by the unaided 
efforts of nature, in a manner which renders any ''assistance" on the 
part of the accoucheur, in the ordinary acceptation of the term, quite 
unnecessary. Indeed, the duties which he has to discharge might, in 
nineteen cases out of twenty, be performed as efficiently and perhaps 
more agreeably to the feelings of the patient by a thoroughly trained 
and intelligent nurse. But, in the twentieth case, something may occur, 
— and, it may be, quite unexpectedly — which suddenly demands special 
experience, operative skill, and a thorough practical knowledge of the 
healing art. It is only, however, as has already been observed in the 
introductory chapter, by a careful study of the normal process, that it is 



PRELIMINARY ARRANGEMENTS. 261 

possible for us to recognize speedily and with precision deviations from 
the physiological standard ; and this reason alone would suffice as an 
apology for a branch of practice which some look upon with disdain. 
But a more important reason still is to be found in the fact that many of 
the dangers and complications of labor arise so suddenly that, unless aid 
is at hand, the life of mother or child, or of both, may be sacrificed ; for, 
as at present trained, it is rare to find a nurse who has the skill 
requisite for the management even of the more remediable complications 
of midwifery. 

There are numerous points of detail which contribute greatly to the 
comfort of the patient, in regard to which an intelligent nurse is usually 
well informed, and the management of which may be left in her hands, 
if we have confidence in her ability. This, however, manifestly applies 
only to the wealthier classes, who alone can command the services of 
such skilled attendants ; but, as the practice of the great majority of 
professional men extends, more or less, in directions where he has himself 
to discharge many of the duties which are more properly those of the 
nurse, it is necessary that every young practitioner should thoroughly 
understand what these are. And, in any case, the failure of the nurse 
may devolve these duties upon him, so that it is of further importance 
that he should be familiar with them, in order that he may be able at 
once to detect incompetency, and to remedy its defects. 

The judicious management of a case of labor may be held to include 
certain preliminaries, in regard to which women, and more especially 
primiparse, ofcen require some advice. The systematic neglect of the 
bowels which Avomen so often practise, is likely, if persisted in, to be a 
cause of much discomfort. A pregnant woman should therefore be en- 
joined on no account, as the period of labor approaches, to neglect this 
function. In most cases, it is proper, by a laxative given at the outset 
of labor, or by the administration of an enema, to make sure that the 
lower bowel is empty ; for, if this be neglected, the labor will be much 
more disagreeable to the accoucheur, and may also be unduly protracted. 
If her health be tolerable, she must not be encouraged to consider her- 
self an invalid, but should be recommended to take such moderate 
exercise as may seem appropriate, while the tone and general vigor of 
the system is maintained by a sufficient diet, which may be generous, 
but not stimulating. During the last weeks of pregnancy, the descent 
of the womb often renders a woman more capable of moving about, from 
which " it would almost seem," as Rigby says, " that nature intended 
she should use exercise at this period, and thus prepare her, by in- 
creased health and strength, for a process which requires so much suffer- 
ing and exertion." 

The perverted and irregular contractions, to which we have already 
alluded under the name of " false pains," may cause the summoning of 
the accoucheur long before his services as such are required. Those pains 
will often, upon strict investigation, be found to depend upon derangement 
of the bowels, or upon reflex irritation starting from some other source ; 
and, in this, as in many other cases, the success of the treatment will 
depend upon the intelligent appreciation of the cause. By mistaking 



262 MANAGEMENT OF NATURAL LABOR. 

false for real pains, we may, in our ignorance, allow the woman to go on 
suffering that which we generally have it in our power to alleviate. 

The practitioner Avill often, to his great annoyance, be called to the 
bedside of his patient, when, although labor may have commenced, the 
period is yet distant at which his services will be required. Such a sum- 
mons should, however, be promptly obeyed. For although, in most cases 
it will be time lost, it is of the greatest possible importance that anything 
abnormal should be detected as early as may be in the course of labor. 
We are then in a position leisurely to determine our plan of procedure ; 
and, should any operative assistance be required, to select that period for 
it which is most favorable in the interests of mother and child. We are 
able, moreover, when we have an early opportunity of examining the case, 
to form an opinion, to which experience will lend confidence, as to the 
probable duration of the case, and this enables us to leave the patient for 
a time, and to attend to such' other of our professional duties as may be 
most urgent. If the symptoms are such as to convince us that the woman 
is really in labor, we should always make an examination before leaving. 
In proposing this, especially in women who are in labor for the first time, 
we should never forget the consideration which is due to the feelings of 
the patient, whatever be her rank in life. For it cannot be otherwise, 
than that a woman must look upon such an examination as is necessary, 
by a person of the other sex, with apprehension, if not with abhorrence; 
but if the necessity be first explained to her in a few kindly words, she 
will rarely fail to appreciate the good feeling which prompts them, and 
will submit without a murmur to whatever may be deemed essential to 
her safety or comfort. A similar feeling should guide us in everything 
we do in the practice of midwifery, and if so, we shall seldom fail to win 
the confidence of our patient. To lay down, however, as some have at- 
tempted to do, rules for the guidance of the young practitioner in this 
respect, is simply absurd ; for, to tell a man of grave demeanor to look 
cheerful, and a man of lively and jocund spirit to look grave, is to make 
both artificial, and more like fools than rational beings, — a state of mat- 
ters little likely to establish confidence or to engender esteem. 

There are certain articles of his armamentarium which the accoucheur 
should look upon as indispensable, and should therefore carry with him 
as a matter of course : these are an elastic catheter, a small phial of some 
approved preparation of opium, and a similar quantity of the liquid ex- 
tract of ergot. To these may be added chloroform and sal-volatile ; and, 
if we are going to any distance, we should certainly take the forceps, 
which does not occupy much room in the gig or saddle-bag, whereas its 
absence may possibly cause many hours of delay, and increased danger. 
It is the duty of the nurse to provide narrow tape or strong thread for 
tying the cord, and to have in readiness the abdominal bandage, scissors, 
hot and cold water, and a supply of napkins ; but, as it will often fall to 
the lot of the medical attendant to see to these preparations himself, he 
should, at least, be provided with such material as maybe depended upon 
for ligaturing the cord ; and we take it for granted that he habitually 
carries with him scissors and a stethoscope. For obstetric use, a stetho- 
scope with an elastic stem is to be preferred. He should also give a 



. POSITION OF THE WOMAN. 263 

general glance around, and see that everything is ready which may be 
necessary for the comfort or safety of the patient. 

In making an examination, the most convenient position for the ac- 
coucheur, as well as the patient, is that which is invariably adopted in 
this country. The woman lies on her left side, with her back to the ex- 
aminer, and near the edge of the bed, which must, if necessary, be pre- 
viously so arranged to admit of this.^ The index and middle finger of 
either hand, — the right being usually preferred, although the left has 
certain advantages, — being then smeared with lard or oil, are passed over 
the perineum, and gently into the vagina up to the os uteri. It is usual 
to select a period of a pain for the examination ; but, if so, the finger 
must not be withdrawn until we have examined the parts in the state of 
repose also, for the protrusion of the bag of waters during a pain makes 
it difficult to ascertain the presentation, without risking premature rup- 
ture of the membranes by undue violence. The points which one ascer- 
tains in the course of the examination are, in the first place, the state of the 
vagina, whether it is soft, relaxed, and well lubricated with mucus. In 
regard to the os uteri, we observe if it is soft and dilatable, or rigid and 
unyielding, and to what extent it has become dilated, if at all. Infor- 
mation is, further, obtained, as to whether the membranes are ruptured; 
whether we have to deal with a natural presentation ; and if there is any 
pelvic deformity or morbid growth which might impede the progress of 
labor. And, finally, we may thus recognize at an early stage prolapse 
of the cord, — a condition which calls for constant care and anxiety, so 
long as the labor may last. With this view, also, it is usual to make an 
examination at the time of the rupture of the membranes, as it is at this 
moment that the loop of the cord frequently descends ; and, besides, an 

J "In the earliest periods of liistorj, women appear to have been delivered in a 
sitting posture, as is described in the first chapter of Exodus. This mode was revived 
in comparatively modern times ; thus Ambroise Pare, in 1573, speaks of a labor-chair, 
with an inclined back, which he preferred to a common bed. Labor-chairs were 
brought into very general use upon the Continent in the beginning of the last cen- 
tury by Deventer, and, although they have been in a great measure discontinued in 
modern times, there are still some districts in Germany where they continue to be 
used. It is a species of chaise perc^e, furnished with straps, cushions, etc., by which 
the patient can fix her extremities, and thus enable the abdominal muscles to act with 
the greatest power. In some remote parts of Ireland and also of Grermany, the pa- 
tient sits upon the knees of another person, and this office of substitute for a labor- 
chair is usually performed by her husband. Labor-chairs, as far as we are acquainted 
with their history, were never used in this country, nor have they been used for the 
last century in France, where the patients are usually delivered in the supine posture, 
on a small bed upon the floor, which has not inaptly been termed lit de mis^re. A 
modification of the labor-chair is the labor-cushion, first used by linger, and after- 
wards by the late Professor von Siebold, of Berliu, and Professor Cams, of Dresden ; 
it is a species of mattress, with a hollow beneath the nates of the patient for receiving 
the discharges which take place during the labor. The patient is compelled to lie 
upon her back during the greater part of labor, and thus maintain the same position 
for some time, which must necessarily become irksome, and even painful to her. In 
this country and in Grermany the patient is delivered upon a common bed, prepared 
for the purpose as above mentioned ; in England she is placed upon her left side, the 
nates projecting to the edge of the bed, for the greater convenience of the accoucheur ; 
in Grermany — except in Vienna and Heidelberg, where the English midwifery has in 
a great measure been introduced by Boer and Naegele — the patient is delivered upon 
her back. In former times, the supine posture was also used in this country, but for 
about a century the position on the left side has been preferred." — A System of 21id- 
wifery by Edward Rigby, M.D. London, 1844. 



264 



MANAGEMENT OF NATURAL LABOR 



examination now enables us, more surely than before, to determine the 
position of the presenting part. The mode of examination above de- 
scribed is represented in the accompanying figure, in which the examination 
is being conducted with the right hand. In most cases one finger, as here 



Fiff. 103. 




Mode of Digital Examination. 

shown, will suffice, and this should always be attempted when the exam- 
ination seems to cause unusual pain. The student and young practitioner 
should avoid making too frequent examinations, for, not only does this 
irritate the parts, but it tends to remove, at each successive examination, 
a portion of the lubricating medium, upon the quantity of which depends, 
in some measure, the satisfactory issue of the case. The practice of 
previously smearing the finger with some bland lubricant is resorted to 
on every occasion in which an examination is found to be necessary, not 
so much to facilitate introduction, — which the abundance of mucus gene- 
rally renders easy enough, — as to supply the place of any mucus which 
may be removed, and in a certain class of cases to protect the finger. 
The operator should never omit, after an examination, to address a word 
or two to the patient in a cheerful tone ; and, if the presentation be natu- 
ral, and you are then able to say so, she will always be gratified by hear- 
ing that " all is as it should be." 

So long as the os uteri is not fully dilated, or, in other words, so long 
as the first stage continues, the patient should be encouraged to believe 
that this is a stage which is merely preliminary to the act of parturition ; 
and that, therefore, she should not lie in bed, but rather walk about in 
the intervals between the pains, and take such light food as she would 
under ordinary circumstances. If she can be induced to occupy her 
attention, as far as possible, by any familiar occupation, however trivial, 



PREPARATION OF THE BED. 265 

it ^Yill be to her advanta_2:e, by relieving the tedium of her suffering. If 
this cannot be done, her attendants should try, by cheerful conversation, 
to beguile the time, and to divert her mind from the gloomy apprehen- 
sions which are of frequent occurrence at this period. The accoucheur 
should not remain in the room during this stage unless there be any spe- 
cial necessity for it, although he may visit it occasionally. To do 
otherwise would encourage her to expect assistance at his hands, which 
it is not in his power to afford ; and, moreover, his presence would to her 
seem to imply that he expected a speedy termination of her sufferings. 
During this period, the woman is frequently advised by ignorant attend- 
ants to press down, and with this view footstools are placed at the foot of 
the bed, and towels are tied to the bed post, by means of which she may 
fix the trunk, and bring the whole force of the expiratory muscles to 
bear. This acts most injuriously on the progress of the labor, for the 
stage is one of dilatation, and not of propulsion; and, if the muscles re- 
ferred to are thus brought prematurely into play, the voluntary expulsive 
force is fruitlessly expended before the stage arrives at which it may 
properly be employed. Xothing, in fact, is more certain, than that any 
attempt, either on the part of the woman or on the part of the practi- 
tioner, by forcible dilatation of the os, the administration of ergot, or the 
exhibition of stimulants, to hurry delivery, must be strictly avoided in 
the course of the first stage of a natural labor. And, even in cases 
where its duration is prolonged far beyond the average, this of itself is 
no excuse for interference, unless the general symptoms indicate that it 
is our duty to accelerate the labor by such means as are within our 
reach — a state of matters which is of rare occurrence. "When the pains 
flag, it has often been found that the aduiinistration of an enema for the 
purpos-e of emptying the lower bowel, acts further as an efficient stimu- 
lant to uterine contraction. 

The pains usually become more severe as the termination of the first 
stage approaches, and at this period it is advisable that the woman should 
go to bed, more especially if she has previously borne children, as there 
is a risk of the sudden propulsion of the child immediately upon the rup- 
ture of the membranes. Previous to this, the nurse prepares the bed — 
which should not be too soft — by placing over it a piece of india-rubber 
sheeting to protect it from the discharges. Upon this a folded sheet, 
about two and a half to three feet in width, is placed across that part 
of the bed upon which the pelvis of the woman lies. By this simple 
arrangement, the sheet may be gradually pulled through as it becomes 
soiled with successive discharges of liquor amnii, or of blood, and at the 
end of the labor it is completely removed along with the final discharges 
which accompany the birth of the placenta. The ordinary night-dress 
which the patient wears, or rather that part of it which is beneath her 
as she lies, should be rolled up above the waist, and the lower part of 
the body covered with a petticoat which opens all the way down, and 
she should then be covered with such bedclothes as the season of the year 
and her own feelings may render necessary. She lies on her left side, 
as has already been stated, with her back to the practitioner, and her 
head consequently to his left hand ; and one of the advantages of such a 
position is that she is not disturbed by seeing such preparations as may 



266 MANAGEMENT OF NATURAL LABOR. 

be necessary for her assistance or relief. It is by no means essential 
that she should occupy this position continuously till the termination of 
labor. To do so would be irksome in the extreme ; so that she may be 
permitted to lie at will on either side, or on the back, reverting necessa- 
rily to the left side wdien any occasion may arise for renewed examina- 
tion. 

For reasons above stated, frequent examinations are always to be 
avoided. From time to time, however, examinations may be instituted 
with the view of ascertaining the rate of progress which is being made. 
This has the further advantage of allowing the busy practitioner to 
absent himself from time to time, for such a period as he judges to be 
quite safe ; but, in this respect, he must always be cautious, as he will 
be blamed if absent at the critical moment. In some cases, even in 
primiparse, a sudden and violent increase in the expulsive force unex- 
pectedly occurs, when, if the parts be soft and dilatable, the birth may 
take place with extraordinary rapidity. All calculations as to the pro- 
bable period of delivery are very uncertain, and although experience 
gives a certain confidence to the opinion vv^hich may be formed, we can- 
not be too cautious in expressing it ; for, not only may it end abruptly 
as we have seen, but, in other cases, labors, which up to a certain point 
have advanced in a manner which seemed to render speedy delivery 
almost a certainty, are suddenly suspended by failure of uterine action, 
or by some other cause. The child may, under such circumstances, 
actually be arrested on the very threshold of its entrance into the world. 

So soon as rupture of the membranes has taken place, the sheet be- 
neath the patient should be pulled by the nurse towards the edge of the 
bed, so that she may rest on a dry portion, and avoid the discomfort of 
lying on a wet bed. The stage of propulsion now usually commences, 
and it is quite proper now to encourage the woman to avail herself of the 
aid of the abdominal muscles. In most cases, she will do this in- 
stinctively, and requires no instruction whatever; but, in others, there is 
a disposition to waste the force of the expiratory muscles in cries which 
are worse than useless, and it is in these cases that encouragement 
should be given. In regard to the means already referred to for fixing 
the trunk, the accoucheur will use his own discretion as to how far they 
are to be permitted ; for, if the pains are of more than usual violence, 
we must rather restrain than encourage her eiforts, while if, on the con- 
trary, they are slow and inefficient, we may, with perfect propriety, 
allow of any means which may act by increasing the deficient propulsive 
force. At any time in the course of the labor, but more especially, per- 
haps, about the commencement of the propulsive stage, difficulty may 
arise from retention of urine, in consequence of mechanical closure of the 
urethra. This requires the use of the catheter, which is to be employed 
with caution and with due reference, as has already been mentioned, to 
the anatomical modifications which attend pregnancy. The pressure 
consequent upon the descent of the head, often gives rise to cramps in 
the thighs, a symptom which sometimes aggravates very greatly the suf- 
fering of the patient. We shall not stop here to consider whether this 
is due to direct pressure upon the large nervous trunks, or to a reflex 
action; but in regard to the treatment of what is a troublesome compli- 



PROGRESS OF THE SECOND STAGE. 267 

cation, although not a dangerous one, it can only be said that if empty- 
ing the bowels by an enema, and warm friction of the thighs, should fail 
to remove the spasm, w^e can but try such other means of palliation as 
may occur to us, for in all probability the patient will not enjoy complete 
relief, until the termination of the labor has removed the cause which is 
responsible for the symptom in question. 

As the head descends in the pelvis, after the termination of the first 
stage, it not unfrequently happens that the anterior lip of the os remains 
in an oedematous condition, indicative of pressure of the anterior uterine 
wall between the presenting part and the symphysis pubis. This consti- 
tutes a very manifest impediment to the progress of the labor. It has 
been said by some of the best authorities that under such circumstances 
we should never interfere. " x\ll attempts," says Rigby, " to push it 
above the head are objectionable, because, in the first place, the finger 
cannot reach sufficiently high to effect the object, and, therefore, the 
swelling descends again to its former situation ; and, secondly, the efforts 
to push it up only tend to inflame it, and increasing the swelling." To 
this we must demur. Any attempt, rudely or forcibly, to push up the 
anterior lip, even when it exists as a manifest impediment, should cer- 
tainly be avoided ; but we are bound to add that, in many cases, it may 
be pushed beyond the head with perfect safety, and in this way the im- 
pediment to delivery may be at once obviated. The swollen part should, 
during the interval between two pains, be gradually and cautiously 
pressed up as far as possible beyond the head. If the finger be re- 
moved, the tumor descends at once, as Rigby saj^s ; but if it be kept in 
position until the next pain comes on, the head will often pass down, and 
the cervix be retracted upon it, precisely as occurs at the moment of 
the passage of the head through the ostium vaginae by the action of the 
levatores ani muscles. This cannot be effected in every instance, but the 
attempt, if cautiously performed, is free from risk, and in a very con- 
siderable proportion of cases, is attended with complete success. 

The further progress of the labor brings the head, or other presenting 
part of the child, downwards, towards the floor of the pelvic cavity. In 
a certain number of cases, it is, however, impeded in its progress by me- 
chanical hindrances, which it is in our power to remove. The membranes, 
for example, may be so tough as to have resisted an ordinary amount of 
force at the period at which they usually give way : or they may be 
distended by a very unusual quantity of liquor amnii ; in either of which 
cases the bag of waters may constitute an impediment to delivery which 
can only be removed by artificial rupture, so as to permit the descent of 
the head. In other instances the os uteri presents a condition of abnor- 
mal rigidity, its margin being, at the acme of a pain, hard, rigid, and 
tender. In former times the practice universally adopted in such a case 
was blood-letting, and we do not for a moment doubt that the effect of 
the operation was to relax the rigidity, and permit the descent of the 
head, and the same remark may be made with reference to the adminis- 
tration of tartar emetic. We have, however, in chloroform or ether, 
agents far preferable which, in such cases, exercise a most powerful in- 
fluence upon the rigidity of the os. We should never fail to avail our- 
selves of these in cases requiring operative interference. In such 



268 MANAGEMENT OF NATURAL LABOR. 

instances, indeed, they fulfil a threefold indication, by subduing the 
rigidity we are speaking of, arresting voluntary movements, and allaying 
reflex susceptibility. Of late, chloral hydrate has been extensively used 
for the same purpose and with satisfactory results ; and in France, 
belladonna has enjoyed a high reputation, Avhich, however, is somewhat 
doubtful. 

The stethoscope should be employed from time to time during the 
course of a tedious labor, to ascertain the vitality and vigor of the foetus, 
for there are cases in which the life of the foetus may be compromised, 
while thab of the mother undergoes no risk whatever. Some, indeed, 
have recommended that, in labor apparently the most uncomplicated, the 
stethoscope should be frequently used, so that risk to the life of the child 
may thus be reduced within the narrowest possible limits. 

When the further progress of the case has brought the head to press 
against the perineum, as is shown in Fig. 100, it distends or bulges that 
structure outwards, or rather downwards, more and more during every 
succeeding pain ; and the position of the patient on the left side enables 
us often to watch the process without her being aware of any exposure. 
The axis of motion is now no longer downwards, but forwards in the direction 
of the sub-pubic angle, as will be fully described in a subsequent chap- 
ter. A very usual practice at this stage, is to separate the knees by 
means of a pillow or otherwise, so as to encourage, as far as possible, 
the movement in this direction. This has, however, been condemned by 
some of the best authorities, on the ground that labor should be habitually 
retarded at this stage, an argument, the force of which, we confess, we 
can scarcely admit. And this for two reasons : first, because the posi- 
tion on the side, which involves apposition of the knees, is singularly un- 
favorable to movement of the head in the direction which we have 
indicated as normal ; and, second, because, in a large majority of cases, 
the separation gives the woman great relief, a fact which is familiar to 
every experienced nurse. 

The most important point, however, connected with this stage of the 
process is, undoubtedly, the Support of the Perineum — a mode of pro- 
cedure which is recommended in some form or other by most writers on 
obstetrics. Many years ago, our attention was, by an accidental circum- 
stance, very particularly directed to this matter, and we published some 
time afterwards a paper on this subject,^ which was founded not only on 
a careful clinical study of the phenomena of this stage of labor when 
unaided, but also on a critical examination of the views entertained by 
those who practise support of the perineum, and of the reasons which 
swayed them. The points brought out were mainly these : — 

The earlier writers recommend only, in reference to this stage, the 
free use of lubricants and emollients. About the middle of the last 
century, Smellie advocated artificial dilatation of the external orifice of 
the vagina ; Puzos, stretching of the parts along with lubrication ; and 
Roederer, pressing of the perineum towards the sacrum ; all these modes 
of treatment differing greatly from the modern procedure. To whom 
the practice of perineal support is originally due is a matter of doubt, 

* Glasgow Medical Journal. January, 1860. 



MANAGEMENT OF THE PERINEUM. 269 

but, in the treatise published by Professor Hamilton of Edinburgh, in 
1781, we find it mentioned as a distinct system, applicable alike to natu- 
ral labor and to that which is in any way abnormal. This author, like 
Puzos, advocates the use of lubricants, and recommends us to release the 
perineum Avhen the head is being born, " by cautiously sliding it back 
over the face and chin of the child." From this time writers have, in 
the main, agreed that, by a support of the perineum, lacerations are to 
be prevented : but they have not agreed as to what " support" is, or to 
what extent it is to be practised. It would carry us far beyond the limits 
within Avhich the subject must here be confined to examine critically the 
views which are, or have been, entertained by the most approved authori- 
ties on this point. We shall, on this account, refer only, and that very 
briefly, to the opinions which are promulgated by some of the authorities 
referred to. 

Dr. Ramsbotham says — "As soon as the head has come to press on 
the external parts, it becomes our duty to take our seat by the bedside, 
and never to move from our position till the child has passed. This we 
do to protect the perineum and to prevent laceration." . . . " Place 
your elbow," he continues," against the bedstead, regarding it as a fixed 
point, and allow the perineum to be forced against your hand." Fortu- 
nately there are few, if any, teachers of midwifery who go to such an 
extreme in the recommendation which they give to their students ; for 
we believe that support of this kind can scarcely fail sometimes to bring 
about the very accident which we are striving to avert. Dr. Tyler Smith 
pointed out many years ago, that pressure upon the perineum is apt to 
excite the uterus to increased contraction by a reflex action starting from 
the nerves which are distributed through the former structure, and on 
this ground he dissuades us from practising systematic support. Churchill 
recommends very gentle and careful support, and, in concluding his 
observations on this point, informs us that it has been his lot to " witness 
more than one case Avhere rupture was owing to excessive and injudicious 
support." Denman only sanctions support in first cases, wiiile Naegele 
plainly says " under ordinary circumstances, any support of the perineum 
is unnecessary." 

It was a careful study of these opinions among others, along with a 
thorough observation of the process in nature, which led us long ago to 
condemn support of the perineum as irrational and useless in all cases, 
and undoubtedly hurtful in some. It must be admitted, however, that 
the method usually adopted, which consists in very gentle support, with 
the view, mainly, of directing the head forwards, probably does no harm ; 
the palm of the left hand, protected by a napkin, being laid along th3 
perineum, and pressed against it during a pain. Two points must here, 
however, be borne in mind ; that the perineum must sooner or later yield, 
and that support necessarily implies opposition to the progress of the 
head. If, therefore, w^e admit support as a rule of practice, we shall 
find ourselves opposing a natural process, and presuming to teach nature 
a lesson. If any one will but take the trouble in a single case to watch 
the admirable manner in which nature effects her purpose in dilating the 
perineum, each pain increasing the dilatation by a carefully graduated 
force, until at last the orifice permits the passage of the head, the obser- 



270 MANAGEMENT OF NATURAL LABOR. 

vation will go further to convince the most earnest advocate of the doc- 
trine of support than any mere argument can do. And be it remem- 
bered always, that rupture of the perineum will occur in a certain pro- 
portion of cases, do what we may. 

The practice of perineal support, then, is, if very gentle, harmless. 
Indeed, we are inclined to admit that, in some cases of deficient contrac- 
tile power, it may be beneficial, but in a way very different from what 
the operator counts upon — by exciting more energetic propulsive action. 
The practitioner, however, who never puts his hand to the perineum will, 
we firmly believe, have fewer cases of ruptured perineum in his practice 
than he who admits support in any form as applicable to every case of 
labor ; while, if he adopts the advice of Ramsbotham, as above quoted, 
he will, beyond all reasonable doubt, increase the danger of rupture. 
We do not think, in reference to this subject, that we take an exaggerated 
view of the case in looking upon it as a relic of " meddlesome mid- 
wifery," in which we presume by irrational and bungling interference to 
dictate to nature. 

The proper management of this stage — which will be found to be at- 
tended with results of the most satisfactory kind — consists in watching 
the amount of pressure to which the perineum is being subjected. This 
may be done effectively and easily by keeping a finger on the anterior 
margin of the perineum, which enables us, with a little practice, to gauge 
with tolerable accuracy the degree of propulsive force which is being ex- 
ercised. Should this exceed the normal standard, so as to imperil the 
integrity of the tissues, we must then order all aids to expulsive effort to 
be removed from the reach of the patient, and at the same time encour- 
age her to cry out lustily during the height of a pain, or, in other words, 
to make free use of the safety valve of the glottis. Should circumstances 
render it expedient to oppose the advance of the head with the view of 
rendering the process of dilatation more gradual, this should be done, 
not by pressure on the perineum, but by pressure exercised directly upon 
the head of the child, which is to be pressed towards the hollow of the 
sacrum. But the effect even of such pressure is in most cases doubtful, 
and the greatest possible care must be exercised lest we divert the force 
which should be expended in the direction of the pubic arch, and, by 
bringing it to bear directly upon the perineum, thus enhance its risk of 
rupture. 

In all first cases, the fourchette is slightly lacerated, but the rupture 
seldom extends further. In cases in which there exists morbid rigidity, 
cicatrices, or a diseased state of the parts, the rent may extend deeply 
into the perineum, and even in extreme cases through the sphincter into 
the anus. We must guard, however, against taking too serious a view of 
such a laceration; for what may seem at the moment of delivery to be a 
serious surgical lesion, turns out in the course of forty-eight hours, and 
in consequence of the retraction of the parts, to be but a trifling fissure. 
It is not, as a rule, by the passage of the head that the most serious 
lacerations are effected; they are often commenced by this, but it is the 
passage of the shoulders which extends the rupture. Sometimes, the 
perineum gives way under an amount of pressure which is comparatively 
trifling, suddenly yielding in its whole extent like a piece of wet parch- 



SUPPORT OF THE PERINEUM. 271 

ment ; and it is in regard to these cases that a suspicion has arisen as to 
the possibility of disease in the structure of the parts. There is also an 
increased risk of perineal rupture in certain forms of pelvic deformity — 
such as diminution in the transverse diameter of the outlet. This in- 
volves an approximation of the tuberosities of the ischia, and an abnormal 
acuteness of the sub-pubic angle — conditions which obviously must make 
the head pass further doiuyiwards in the direction of the perineum, before 
it is possible for it to move forwards under the arch. Unskilful manipu- 
lation, with or without instruments, is also a fertile cause of perineal 
rupture. Certain rare cases are recorded in w^hich the child has actually 
passed through the perineum, by forcing a passage through this structure 
and the anterior wall of the rectum, while the posterior commissure of 
the vagina remained unruptured. 

Rigidity of the perineum is an affection which sometimes causes a very 
serious impediment to the completion of labor. If it be simple rigidity, 
unconnected with any lesion, and accompanied with dryness of the parts, 
the treatment applicable in the case of rigid os may be tried here also, 
for there is no doubt that in such a case, chloroform, ether, or chloral 
hydrate, would have a beneficial action ; and there is no reason that we 
can see why, in such cases, the old-fashioned treatment by lubricants may 
not be useful. But there are cases in which rigidity is the cause of rup- 
ture ; and, when the latter is impending, we may occasionally be justified 
in making a slight incision with a lancet, or tear with the finger nail if 
possible, on each side of the ostium vaginae, as has been practised by 
some of the most distinguished accoucheurs. In this case, the laceration 
which attends the passage of the child is, both in direction and in extent, 
a matter of very little importance. This is an advice, however, that one 
is almost afraid to give to the inexperienced, as there is much risk of its 
being improperly and unnecessarily resorted to. Cases in which, in the 
absence of structural disease, rigidity in this situation constitutes an im- 
passable barrier to delivery are very rare ; but they do occur, and, when 
present, may require free incisions to permit of the passage of the child. 
The treatment of perineal laceration will be referred to in another place. 

When the passage of the head is completed, we should ascertain if the 
cord is around the neck, and if so, it must be slipped over the. shoulders, 
or pulled down so as to protect the neck from injurious pressure. One 
hand is to be placed over the fundus uteri, which is to be gently pressed, 
and followed in its descent by the hand, — a practice which tends to pro- 
mote the speedy separation of the placenta. Unless there are symptoms 
of threatened asphyxia in the child, or circumstances which demand im- 
mediate delivery, we should not in any way interfere in the birth of the 
trunk, which will be naturally effected after a short pause, generally 
counted by seconds. We must now place the child in such a position as 
will enable it to breathe freely ; and, should efiicient respiration not im- 
mediately ensue, — the best evidence of which is a loud cry, — it will be 
our duty at once to adopt such means as are best suited to excite respi- 
ratory action. The stimulus afforded by exposure to the external air, along 
with certain centric causes arising from deficient aeration of the blood, 
are generally sufficient to excite the muscles which contribute to the act ; 
but, should these fail, it will be proper, by blowing on the face, a smart 



272 MANAGEMENT OF NATURAL LABOR. 

pat on the nates, or sprinkling with cold water to set the function agoing 
without delay. Failing this, the infant should be plunged into a basin of 
warm water, and cold Avater plentifully dashed upon it as it is removed 
from the bath. The tongue should be drawn forward, the mucus rapidly 
removed from the fauces as far as is possible, and regular attempts at 
artificial respiration persevered in so long as the slightest action of the 
heart continues. In cases of suspended animation, the cord should not 
be tied until it has ceased to pulsate, as there is a possibility, in such 
circumstances, of a certain amount of placental respiration. The child 
is also threatened with asphyxia in cases where it is born along with the 
unruptured membranes, and thus remains, after its separation, enveloped 
in its intra-uterine coverings and bathed in the liquor amnii. In this case 
the membranes must be instantly ruptured, and aerial respiration estab- 
lished.^ 

The infant being born, and having given proof of its independent 
existence, our next duty is to ligature and cut the cord. The material 
to be used as a ligature is a matter of no very great moment^ provided it 
be of sufficient strength, some preferring strong thread, and others an 
agent which, while it compresses efficiently, is not so incisive as the ordi- 
nary surgical ligature, by which the gelatine of Wharton is actually cut. 
The material preferred by the latter is strong narrow tape, of which the 
narrow red tape of national tradition afibrds a good example. The liga- 
ture should be placed aboat two or three inches from the umbilicus, and 
should be drawn with sufficient tightness to prevent the possibility of 
oozing. The knuckles should be brought together, w^hile the knot is 
being drawn, to steady the hands ; for, were the ligature to snap, in the 
absence of this precaution, the funis might be torn from the umbilicus or 
its placental attachment, and thus give rise to much trouble and some 
risk. The reason of applying the ligature at such a distance from the 
umbilicus, is to leave room for another should the first fail. It is usual 
to apply a second ligature on the placental side of the first, and to cut 
the cord between the two ; but the advantage of the additional one con- 
sists entirely in preventing the fluid contents of the umbilical vessels from 
further soiling the bed linen. In reference to this. Dr. Dewees, who 
disapproves of the application of a second ligature, observes that " the 
evacuation from the open extremity of the cord will yield two or three 
ounces of blood, which favors the contraction of the uterus and expulsion 
of the placenta." In the case of twin pregnancy, a second ligature 
should always be applied, as the cords occasionally communicate. 

The child being separated and handed to the nurse, there only now^ 
remains, to complete delivery, the Third Stage, or expulsion of the Pla- 
centa: If the directions above given have been observed, and the fundus 
uteri followed by the hand, and firmly compressed at the termination of 
the second stage, little difficulty will be experienced in regard to the 
speedy and satisfactory termination of the case. If we do not feel that 
the uterus is firmly contracted behind the symphysis, we may attempt by 

1 In this case the child is said to be born with a " caul." It is supposed to be in- 
dicative of good luck and prosperity, and in seaport towns the caul is carefully pre- 
served, and is believed by the credulous to be a talisman which protects the wearer from 
death by drowning. 



SEPARATION OF THE PLACENTA. 273 

friction over the fundus to excite it to contraction; if , on the contrary, it 
is quite firm, the case may be left absolutely to nature, when expulsion 
will usually occur in from ten to twenty minutes. But what is, in its 
results, a much more satisfactory method of procedure is to keep the 
hand upon the uterus, and to aid its contraction by means of firm pres- 
sure. This method of expression, or squeezing the placenta and mem- 
branes out of the womb, has long been practised ; but fortunately, of 
late years, more particular attention has been directed to it under the 
name of "Crede's method," so that this mode of managing the third 
stage is now becoming — as it ought to be — very generally adopted. In 
this way, a very few minutes will usually sufiice for the passage of the 
placenta, its ultimate emergence being eifected by the action of the mus- 
cular fibres of the vagina and perineum. Pulling on the cord should, if 
possible, be avoided. 

[Crede's method of delivering the placenta is to seize the uterus, with 
the fundus in the hollow of the hand; the four fingers being applied to 
the posterior, and the thumb to the anterior surface of the organ. The 
relaxation of the abdominal walls enables the phj^sician to do this readily, 
so that he has the organ thoroughly under control. The uterus is then 
firmly compressed, when the placenta is expelled, sometimes with a gurg- 
ling noise. This method of delivering it is especially valuable during an 
epidemic of puerperal fever, and when the general practitioner has under 
his care diseases which he fears might be transmitted to his puerperal 
patient by inoculation. — P.] 

Should any unusual delay or special difficulty arise, it will then be 
proper to pass a finger into the vagina, using the cord as a guide, in 
order to ascertain whether or not the separation of the placenta is com- 
plete. When, with a single finger, we can reach with ease the insertion 
of the cord, we may infer that the placenta, or at least the greater part 
of it, is in the vagina, and under such circumstances we may attempt to 
hook down its edge, at the same time drawing gently on the cord. But 
when we find the cord passing up into the uterus beyond our reach, the 
edge of the placental mass which presents at the os uteri being alone 
accessible, we know that the placenta, although possibly completely 
separated, has not as yet been expelled from the uterus; and, after 
pausing for a few minutes, we again endeavor, by forcible compression 
applied by both hands to the fundus and sides of the womb — the fingers 
being directed to the pubes — to awaken the dormant uterine energy, to 
assist such pains as may be present, or to imitate them if absent. It 
will be necessary, however, in a certain number of instances, to assist 
nature in the completion of the process. An intelligent apprehension of 
the manner in which the placenta is naturally expelled, which is de- 
scribed in the preceding chapter, will prevent us under such circumstances 
from doing what is too common in midwifery practice, viz., forcibly 
pulling on the cord. In a large proportion of cases, the delivery of the 
j^lacenta may doubtless by this means be effected, it being hauled through 
like an inverted umbrella, but the amount of hemorrhage, at the time and 
afterwards, may thus be very unnecessarily increased. The proper 
course is to pull down the presenting portion of the placenta, using only 
such traction upon the cord as may assist us in effecting this object. Our 
18 



274 MANAGEMENT OF NATURAL LABOR. 

first eiForts of extraction should be made in the axis of the uterus, back- 
wards and downwards. This is to be altered, as soon as the placenta 
passes into the vagina, to a direction downwards and forwards, corre- 
sponding to the axis of that canal. Should we fail in this attempt, or 
should there be danger of a portion only of the placenta being removed, 
it will be proper to introduce cautiously the hand into the uterus to such 
an extent as may be necessary for the complete extraction of the mass ; 
and, if it should then be found, as is sometimes the case, that morbid 
adhesions exist, these must be broken down in their whole extent, and 
the hand, if possible, not removed until the entire placenta is brought 
with it. Irregular contraction of the uterus may also prevent its expul- 
sion, and of this a familiar variety is described as " hour-glass" contrac- 
tion, the organ being retained in the upper segment by a constriction. 

When the placenta is expelled, or has been extracted, it is well to 
look at its uterine surface to see that no portion of it has been left 
behind ; and it is also of importance, as it escapes from the external 
parts, that the adherent membranes should pass along with it, as other- 
wise a portion of them may be torn off and left behind in the uterus. 
With this object in view, we are advised to twist or rotate the placenta 
as it is passing the vulva, the membranes being thus twined into a sort 
of rope which renders them less likely to tear. The uterus is now to 
be examined, and we must satisfy ourselves of its existence in the form 
of a firm tumor behind the pubes about the size of a child's head. The 
prepared sheet being now pulled from beneath the woman, and with it, 
as far as possible, the discharges, she may be allowed to lie on the back, 
with the legs extended and the knees together. In this position, the 
condition of the uterus may be still more satisfactorily ascertained, and 
it is a good plan in practice to place the hand of the patient over the 
uterus, and instruct her to press gently upon it occasionally, which 
insures the expulsion of any clots which may be retained, and, in the 
case of pluriparye, has an excellent eifect in moderating after-pains. So 
soon as we are satisfied with the contraction of the uterus, and the 
Avoman has been made comfortable by the removal of the petticoat, and 
rolling down of the night dress which has thus been preserved from the 
discharges, a dry napkin is placed over the pudendum, and the abdominal 
bandage applied. The object of this bandage, the propriety of which 
has been disputed, is to afford the uterus and other organs some support, 
as a substitute for what they have lost in the sudden relaxation of the 
abdominal walls. If there is any tendency to hemorrhage, it is usual 
to fold a towel in the form of a pad, and place it beneath the bandage 
over the uterus, so as to exercise more direct pressure over that organ. 
Another and subsequent use of the bandage in the hands of a skilful 
nurse is the preservation of a woman's figure, a matter to her of no little 
importance. Bandages are often shaped, in which case they have some- 
times a T bandage attached to keep the napkin in contact with the ex- 
ternal parts. In ordinary practice, nothing is better than a bolster cover, 
which, when pinned firmly over the abdomen, serves the purpose admi- 
rably. 

So soon as the bandage has been applied and the comfort of the 
mother otherwise attended to, the nurse is at liberty to dress and 



DEFINITION OF MECHANISM OF LABOR. 275 

attend to the child. The patient must be strictly enjoined to maintain 
the horizontal position, as fatal cases have occurred in women who 
had imprudently assumed the erect posture shortly after delivery, and 
had thus established such hemorrhage as immediately proved fatal. 
A single glass of sherry or claret with water may be allowed ; but it is 
truly astonishing how seldom this is necessary, so admirably is the 
eftbrt even of weakly women compensated for. It is advisable for the 
practitioner not to leave the house too hurriedly, until he feels confident 
that all is well, and, more especially, that there is no tendency to 
post-partum hemorrhage. An excellent physiological method of avert- 
ing the latter is to put the child early to the breast, which seldom fails 
to excite reflex uterine contraction ; and this acts otherwise advantage- 
ously, although there is no milk in the breasts, by drawing out the 
nipples. 



CHAPTEE XYII. 

THE MECHANISM OF LABOR. 

Definition of Mechanism of Labor. — Difficulty and Importance of the Subject — 
Historical Sketch: Views of Sir Fielding Ould ; of Smellie ; of Saxtorph ; of 
Solayr^s de Renhac ; and of Naegele. — Natural and Faulty Presentations. 

Cranial Presentations : Occipito- Anterior and Occiinto-Posterior Varieties, — 
First Position : Pelvic Obliquity : Occipito- Frontal Obliquity^ or Flexion : 
21ie Head '•'■at the Brim :^' Examination of Fontanelles and Sutures. — Rota- 
tion; Causes of. — The '•'■Presentation.,^^ or ^'■Presenting Point." — I'he Caput 
Succedaneum. — 17ie Chin leaves the Chest. — Further Descent and Birth of the 
Head. — Obliquity of the Outlet. — Moulding. — External Rotation or Restitution 
of the Head. — Second Position : The Converse of the First. — Resume of 
Mechanism in Occijrito- Anterior Positions. 

The primary idea of Labor comprises three secondary ideas : a body 
which is to be propelled, a force by means of which the propulsion is to 
be eifected, and a passage through which it takes place. The mechanism 
of birth thus includes, in its most comprehensive sense, all mechanical 
questions which spring from the elaboration of these three ideas. The 
various points connected with the anatomy of the parts, and arising from 
a consideration of the various forces which contribute to effect the expul- 
sion of the child, having been already fully discussed in preceding chap- 
ters, there remains still for careful study, the relation which the body 
propelled bears to the canal during the different stages of labor. It is in 
this higher though more restricted sense that the term Mechanism of 
Labor is employed, and a study of this subject includes, therefore, a 
thorough and critical examination of the physical laws according to which 
the process of parturition is effected. 



276 THE MECHANISM OF LABOR. 

A knowledge of this section of the subject has been fitly described as 
the keystone of the art of obstetrics. For, without an intelligent appre- 
hension of the various doctrines involved, the practice of midwifery is 
reduced to a mere handicraft, in which a certain amount of manual 
dexterity may be attained, but which, under such circumstances, is utterly 
unworthy of the dignity of a science. We cannot, therefore, too earnestly, 
nor too emphatically, urge upon the student the necessity of mastering at 
the outset this important subject, upon which a great part of what is to 
follow is founded. It is not by any means an easy matter, just at first, 
clearly to understand the descriptions given in books, or to follow at the 
bedside the process so described. This demands sustained attention, and 
a perseverance which is apt to be bafiled by the peculiar circumstances 
under which the investigation is conducted. We may here mention 
shortly what the chief difiiculties are, and how they may in some measure 
be avoided. 

The most effective descriptions, and such as are most useful to the 
student, are, undoubtedly, those in which unnecessary complication is 
most scrupulously avoided, and in nothing is simplicity more essential 
than in the various classifications of labor according to the position of 
the child within the pelvis. A simple system ought, therefore, in every 
case to be preferred : in regard to such as are more complicated, it has 
been well observed that divisions and subdivisions may be multiplied 
almost at will. The chief difficulty of the beginner arises from the 
somewhat complex mental process through which alone he can determine 
the presentation and position of the child in any given case — a difficulty 
which the obstetric posture in this country somewhat increases. For not 
only have we to figure to ourselves the child with its axis inverted — 
standing, so to speak, upon its head, which is towards the os uteri — but 
we have also to allow for the posture of the woman, lying, as she does, 
horizontally, or with the long axis of her body at right angles to that of 
the accoucheur. Some of this difficulty is avoided by remembering that 
in almost all cases the right side of the child corresponds to the right side 
of the mother ; that its back is turned to her anterior or abdominal sur- 
face, and that its head is downwards in the direction of the os. These 
are the first points which it is necessary clearly to understand in regard 
to the anatomical relations of the child in natural labor ; but, essential 
as such preliminary knowledge is, it has no direct reference to what is 
known in modern times as the mechanism of labor. 

The facts just stated comprise well-nigh all that was formerly known 
in reference to the child during labor, and their observation led to very 
erroneous conclusions as to the manner in which its birth takes place. 
Previous to 1741, it was, as far as we can judge, commonly assumed that 
there was no special mechanism of labor beyond the mechanism which 
attends any vital expulsive act, and that the passage of a fecal mass or 
a half-organized clot was as little regulated by fixed mechanical laws as 
was the birth of the child. The universal belief was, that the child lay 
in the womb with the face directly backwards ; and that, in its descent 
through the pelvis, it never altered this position in its course from the 
brim to the outlet, " so that," to use the words of one of the writers of 
that period, " it seems, when she lies upon her back, to creep into the 



SIR FIELDING OULD. 277 

world on its hands and feet." As in regard to most great discoveries, 
so in this instance was the dev^elopment of more correct views a gradual 
process, and the result of the investigations of successive observers. It 
was from first to last a process, in the case at least of those who con- 
tributed in any considerable degree to its advance, of close inductive 
reasoning, according to which, step by step, during a period of about 
eighty years, the subject gradually emerged from obscurity. Nothing 
tends so much to impress upon the mind the great facts which have been 
disclosed in the course of this investigation, as a narrative of the succes- 
sive steps by which the truth was ultimately attained ; and we shall, 
therefore, here call attention to the more important contributions which 
have from time to time been made in this direction. 

The honor of the first step in the process of demonstration is undoubt- 
edly due to Sir Fielding Ould, of Dublin, who published to the world, 
about the date above mentioned, a statement to the effect '' that the 
breast of the child does certainly lie in the sacrum of the mother, but 
the face does not ; for it always (when naturally presented) is turned 
either to one side or the other, so as to have the chin directly on one of 
the shoulders." The idea here invoU^ed is the twisting of the neck, so 
as to bring the long diameter of the head into parallelism with that of 
the shoulders, the greatest diameter both of the head and the trunk being 
thus arranged so as to avoid the limited antero-posterior measurement 
of the brim. The step next in succession was achieved by Smellie. 
This excellent obstetrician, whose work is still deservedly ranked among 
the classics of English midwifery, confirmed Quid's observation that the 
long diameter of the head occupied the transverse diameter of the brim, 
as it found, in that direction, the most ample accommodation. But to 
this, he adds, as the result of his own observations, that the long dia- 
meter of the head rotates at the outlet into the antero-posterior diameter, 
which his measurements, allowing for the recession of the coccyx, clearly 
indicate as the best. In many respects, the views enunciated in this 
admirable work come much nearer the truth than some of a later date ; 
and its translation into several continental languages brought the opinions 
of the author prominently under the observation of the medical schools of 
Europe. From that time, indeed, no writer of note in any language has 
failed to pay his tribute of admiration to the importance of Smellie's 
works, and the genius of their author. 

The work of Smellie found continental obstetrics in a most unfavorable 
state as compared with the English school, and provoked much unfavorable 
criticism. Steadily, however, his ideas gained ground, although consid- 
erably disturbed by the excitement of those who joined with Levret in 
forming what Ave may term the geometrical school of obstetrics, and w^ho 
believed w^ith their master '' that labor was a purely mechanical opera- 
tion, and susceptible of geometrical demonstration." The ultimate adop- 
tion by the most able continental obstetricians of the views of Smellie 
undoubtedly preceded the brilliant results which a few years later were 
disclosed, and for which we owe them so much. It was admitted, as 
proved by Smellie, that there is a determinate relation between the 
pelvis and the child's head during the whole time of labor. Bat the 
point, now for the first time disclosed, was that the head passes into the 



2T8 THE MECHANISM OF LABOR. 

pelvic cavity, in a position which corresponds neither to the transverse 
nor the conjugate diameter, but is intermediate between the two, or ob- 
lique. The names of Saxtorph, of Copenhagen, and Solayres de Renhac, 
of Montpellier, are specially connected with the discovery and announce- 
ment of this fact, which was published almost simultaneously by them about 
1771. The discovery had, however, been made at an earlier period by 
Berger, whose pupil Saxtorph had been not later than 1759. Of this, 
indeed, there is internal evidence in Saxtorph' s works, who, far from 
claiming originality, says in a note to one of his papers on this subject, 
'' In a similar manner, Berger saw the true position of the head in labor, 
and imparted it in his lectures." But, however this may be, it is certain 
that, but for Saxtorph and Solayres, this great truth would have remained 
unknown, possibly even to the present day. We have elsewhere^ stated 
and fully analyzed the views of these distinguished observers, at a length 
which is here impracticable. We may state, however, in general terms, 
that the discovery with which their names will always be connected em- 
braces the fact that the long diameter of the head not only occupies in 
the pelvis an oblique diameter, but that it occupies most frequently the 
right oblique diameter.^ Solayres gives, further, an elaborate account 
of the mechanism of labor in the different cranial positions, and in this 
he is followed by his pupil and enthusiastic admirer, the celebrated 
Baudelocque : the tendency of both writers being to run into too great 
elaboration in classification and description. Baudelocque seems in some 
measure to have recognized the rotation which takes place in occipito- 
posterior positions. Between Baudelocque and Naegele no name occurs, 
the mention of which is essential to the elucidation of the subject in 
question. 

In 1818, Professor Naegele, of Heidelberg, published, on this subject, 
a small pamphlet, of insignificant appearance, which was, nevertheless, 
destined to exercise a greater influence, in regard to this question, on 
the professional mind than all the ponderous tomes of the hundred years 
immediately preceding. " No other work of equally small size," as Dr. 
Tyler Smith well observes, " ever exerted greater influence upon any 
branch of medicine than that of Naegele upon midwifery. It may be 
termed, indeed, the Euclid of Obstetrics ; but it will not have executed 
its mission until every accoucheur, in each individual case coming before 
him, entirely masters the position of the foetal head. Nothing less than 
this should be aimed at by every obstetric practitioner." Without in any 
way attempting to detract from the merit of Naegele — a merit which will 
have its recoo-nition so lono; as medical science has a name — we believe 
that the views promulgated by him have been too implicitly believed in 
and adopted by the majority of obstetric writers. The translation of his 
essay by Rigby, and the enthusiastic defence by the latter of every theory 
and doctrine which emanated from his master, produced a powerful im- 

' The Mechanism of Parturition. London, Churchill, 1864. 

2 The student will carefully note the fact that, in this work, the two oblique dia- 
meters take their name "right" or "left" from the sacro-iliac synchondrosis from 
which they spring. This has already been stated in an early chapter, but is here 
repeated, as unfortunately, by some writers, the nomenclature of these diameters is 
reversed. (See p. 43.) 



PRESENTATIONS. 279 

pression ; and, in point of fact, from that time, English writers have, 
with few exceptions, reproduced without modification, and as demonstrated 
facts, the whole of the conclusions of the great German obstetrician. 
Indeed, it is not too much to say, that the view generally entertained, 
even by the ablest writers, amounts to this — that the subject had been so 
expounded by Naegele that there was nothing further to demonstrate, 
that every problem and theorem was solved, and that his conclusions were 
to be accepted as an absolute solution of all the difficulties and perplexi- 
ties of the past. 

Some have ventured, however, both in this country and abroad, to 
demur to this, and to assert that the matter is not yet at rest, and that 
the ipse dixit, even of Naegele, is not to be admitted as infallible. And, 
indeed, if we reflect as to what was the state of the subject when he 
wrote, while acknowledging that there is that in his discoveries which 
merits all the fame which attaches to his memory, we can scarcely con- 
ceive it possible that one mind could so grasp all the details as to make 
chaos order, and leave no point unassailable, no question unsolved. In 
forming his conclusions, no one could be more earnest and faithful in his 
observations of nature than Naegele ; but, in some respects at least, he 
was mistaken, and from some of his facts he drew erroneous inferences. 
To him is due the whole credit of showino; — althouo;h he exa2:o;erates 
it — that the head not only lies in the right oblique diameter, but lies there 
in a preponderance of cases such as had never been dreamed of. He 
demonstrated also, for the first time with clearness and precision, what 
had before been somewhat obscurely described by Solayres and Baude- 
locque — the rotation which naturally occurs in occipito-posterior positions 
of the head. And he showed that, in ordinary labor, the forehead does 
not rotate completely into the hollow of the sacrum, but still retains, in 
a certain degree, its oblique position. Finally, he asserted, and is ad- 
mitted by most systematic writers to have proved, that there exists, on 
the part of the head in its descent through the pelvis, a hi-parietal obli- 
quity, according to which one ear is approximated to the corresponding 
shoulder. We accept, in general terms, all its conclusions, with the ex- 
ception of the last, to the investigation of which we have devoted much 
time and patience, and conclude unhesitatingly, with Velpeau, Cazeaux, 
Matthews Duncan, and many others (the number of whom is constantly 
increasing), that no such bi-parietal obliquity as Naegele described exists 
as a normal phenomenon of natural labor. ^ 

Presentations. — The term " presentation" should, as has already been 
stated, only be employed to express the relation which the long axis of 
the child bears to the axis of the uterus ; and should never be confounded 
with " position," which is used in another and more restricted sense. 
We speak, therefore, of presentation of the head, of the breech, of the 

1 To examine critically the views of Naegele on this subject would involve the 
introduction of controversial matter quite unsuitable to a systematic treatise. We 
feel, however, that Naegeie's views have such a hold on British obstetrics, and de- 
mand, as well as deserve, such earnest consideration, that we do not consider our- 
selves justified in passing over with a simple denial any statement to whicli he has 
lent the weight of his great authority. We reproduce, therefore, in the form of an 
Appendix, the reasons which have induced us to reject Naegeie's dictum on this 
point. (See Appendix.) 



280 



THE MECHANISM OF LABOR. 



shoulder, and so on, as representing the part which occupies the os uteri. 
The presentations may be multiplied to any extent, as there is scarcely a 
single point on the surface of the child's body which may not, under 
certain circumstances, offer itself at the os. In proceeding to the con- 
sideration of the various presentations which it is necessary specially 
to describe, and remembering the attitude of the foetus within the womb, 
we recognize the fact that it forms an irregular oval. By either end of 
this oval, delivery may take place naturally, so that we may consider as 
Natural Presentations all the varieties known as cranial, facial, breech, 
knee, and footling cases. When the child lies transversely, the shoulder, 
or some other part of the superior extremity — or, in other words, the 
side of the oval — presents ; and, as those cases can rarely be terminated 
by the unaided efforts of nature, they may be termed Faulty Presenta- 
tions. The following Table, which is given by Dr. Churchill, will give 
some idea of the relative frequency of the various presentations, as de- 
duced from the practice of different individuals : — 





Total No. 


Head pre- 


Breech pre- 


Inferior 


Superior 


Author. 


of cases. 


sentatioas. 


sentations. 


extremities. 


extremities. 


Mad. Boivin . 


20,517 


19,810 


372 


238 


80 


Mad. Lachapelle 


15,652 


14,677 


349- 


255 


68 


Dr. Joseph Clarke . 


10,387 


9,748 


61 


184 


48 


Dr. Merriman . 


2,947 


2,735. 


78 


40 


19 


Dr. Granville . 


640 


619 


2 


3 


1 


Edinburgh Hospital 


■ 2,452 


2,225 


17 


8 


4 


Di-. Maunsel . 


839 


786 


... 


21 


4 


Mr. Gi-regory . 


691 


645 


14 


7 


4 


Dr. Collins 


16,414 


15,912 


242 


187 


40 


Dr. Beatty 


1,182 


1,105 


28 


15 


4 


Mr. Lever 


4,666 


4,266 


59 


29 


12 


Dr. Churchill . 


1,640 


1,119 


35 


22 


9 


Drs. M'Clintockand Hardy 


6,634 


5,815 


140 


61 


26 


Drs. Sinclair and Johnston 


13,748 


11,874 


309 


181 


60 



The enormous preponderance of cranial over all other presentations 
renders a study of the former by far the most important. We shall, 
therefore, in the first place, direct our- attention to the different varieties 
of cranial presentations. In respect of the difficulties which the student 
will encounter, in his endeavor to master this subject, it has already been 
confessed that these are not inconsiderable. But it is only at the outset 
that real difficulty will be met with. With every case we observe, and 
every minute we devote to the subject, what seems almost insurmount- 
able at the first glance will melt away. More and more clearly, as we 
grapple with the minor difficulties which now arise, do we discern the 
great truths upon which the science and art of obstetrics depend. Having 
once fairly mastered the subject, we can never forget it, and so habitual 
and automatic will our observations become, that we shall find ourselves 
unconsciously adding to our stock of knowledge, and storing up valuable 
facts which will stand us in good stead in many an hour of difficulty and 
danger. But, if the student, at this period of his career, fails to acquire 
the requisite amount of knowledge which enables him to perfect the tactics 
eritditus, he will most likely never rise beyond mediocrity in obstetrical 



FIRST CRANIAL POSITION 



281 



and scientific knowledge. Success after a fashion he may reach, but his 
attainments will never much surpass those of an intelligent midwife. 
Once more, therefore, we would urge upon the beginner, with what em- 
phasis and earnestness we can command, to lose no opportunity of ac- 
quiring sound knowledge on so important a subject. Without it, the 
practice of midwifery is weariness and drudgery ; with it, it is a subject 
of constant interest, worthy of, and affording ample scope for, the highest 
scientific acumen. 

As the occipito-frontal or long diameter of the child's head may^ in a 
presentation of that part, lie at the brim of the pelvis in the conjugate, 
oblique, or transverse diameter, or in any diameter intermediate between 
these, the number of Cranial Positions may be multiplied to any con- 
ceivable extent. Admitting the possibility of all these, we at the same 
time recognize the fact, which Solayres de R^nhac has so clearly demon- 
strated, that the occipito-frontal diameter of the head of a mature child 
enters a normal pelvis in one or other of its oblique diameters. This 
admits of but four cranial positions, depending upon the direction in which 
the poles of that diameter are turned. In two the occiput is turned for- 
wards ; and, in two, it is directed backwards : these are called respect- 
ively Occipito- Anterior and Occipi to- Posterior. Four positions, there- 
fore, are described, which are termed First, Second, Third, and Fourth: — 



Occipito-Anterior, 



OCCIPITO-POSTERIOR, 



First Position, 



j Second Position, 
I Third Position, 



Fourth Position, 



f Head in Right Oblique Diameter ; 

\ forehead backwards. 

( Head in Left Oblique Diameter ; 

( forehead backwards. 

f Head in Right Oblique Diameter ; 

( forehead forwards. 

^ Head in Left Oblique Diameter ; 

) forehead forwards. 



[American obstetrical authors and teachers generally describe six 
positions of the cranium, three of which are occipito-anterior and three 
occipito-posterior. They are classified as follows: — 



Occipito- Anterior, 



First Position, 
■ Second Position, 
Third Position, 
I Fourth Position, 
OcciPiTO-PosTERioR, ^ Fifth Position, 



Sixth Position, 



( Head in Right Oblique Diameter ; 
( forehead backwards. 
Head in Left Oblique Diameter ; 

forehead backwards. 
Head in i^ntero-Posterior Diameter 

forehead backwards. 
Head in Right Oblique Diameter ; 

forehead forwards. 
Head in Left Oblique Diameter ; 
forehead forwards. 
^ Head in Antero-Posterior Diameter 
I forehead forwards. — P.] 



Fij'st Position. — The head of the child, which occupies generally, 
above the brim, a position approaching the transverse, with the face to 
the right, assumes, as it enters the pelvis, in the great majority of cases, 
what is called the First Position. The centre of the occiput is turned 
towards the ilio-pectineal eminence on the left side, while the forehead 
is directed to the right sacro-iliac synchondrosis. The long diameter of 
the head tlius lies in the right oblique diameter. So soon, however, as 
the head encounters resistance in its descent towards the cavity, its long 



282 THE MECHANISM OF LABOR. 

diameter ceases to be parallel with the plane of the brim, and nothing 
can be clearer and more obvious than the advantage which is thus ob- 
tained. For this oeeipito-frontal obliquity not only implies the passage 
of the occiput in advance of the forehead, in a degree proportionate to 
the amount of resistance, but, involving as it does a flexure of the neck, 
it thus enables the propulsive force to operate at a greater mechanical 
advantage, so soon as the chin becomes applied to the sternum. It is, in 
fact, the vis a tergo which causes the obliquity, as is most admirably de- 
scribed by Solayre5 in his account of the position which we are now con- 
sidering. The propulsive forces which impel the foetus so situated, are 
communicated, in the first instance, to its vertebral column, the articula- 
tion of which with the base of the skull is much nearer the occipital than 
the frontal pole of the long diameter. This of itself, supposing the re- 
sistance to be equal all round, would be suflicient to cause the occiput to 
take precedence of the forehead ; but the movement is further encour- 
aged by the curving of the spinal column through which the force is 
transmitted. 

No term in midwifery is more loosely used than the expression, " at 
the brim." In reference to this, we observe that the head, in passing 
the brim, offers, first, the vertex,^ then its transverse or bi-parietal 
measurement, and, lastly, its long or occipito-frontal diameter, so that 
although a considerable portion of the cranium has passed the brim, and 
consequently occupies the cavity, it cannot be said to have cleared the 
brim until the occipito-frontal diameter has passed. A reference to Fig. 
104 will render this more intelligible, the line A B there indicating the 

Fiff. 104. 



Cranial Planes as they engage iu the Brim. 

bi-parietal plane, and that which is marked C J) the occipito-frontal 
plane, which cannot pass the brim until the former has descended some 
little way into the cavity. The occipito-frontal obliquity, or flexion of 
the head, no doubt disturbs in some measure the idea thus expressed, 
but this, we believe, can only take place when the resistance is consider- 
able, and occurs at an earlier stage than usual. We hold the head, 
therefore, to be " at the brim," in the proper sense of the term, when 

1 For definition of this term, see p. 132. 



FIRST CRANIAL POSITION 



283 



the long diameter occupies its plane ; but as this can only be approxi- 
mately ascertained, it cannot be held as a definition which is practically 
satisfactory. It is better, however, than using the term as many seem 
to do, without attaching to it any clear meaning whatever. 

While the head occupies the position indicated in Fig. 105, which we 




First Cranial Position. 



assume to be at the brim — and in which flexion has not as yet occurred 
— it is scarcely likely that what we have described as the first stage of 
labor, has, as yet, terminated, or even that the os has reached such a 
degree of dilatation as to admit of a thorough vaginal examination. In 
making such an examination at this time, the first point to be remembered 
is the relation which the finger bears to the uterus and its contents ; for 
most incorrect views will inevitably be adopted if we overlook the fact 
that the axis of examination forms, with the axis of the uterus and that 
of the brim, pretty nearly a right angle. The part of the foetal cranium 
which is lowest in the pelvds, and which the finger first touches, is the 
right parietal bone in the neighborhood of its tuber. ^ But, if the finger 
be pushed farther back, so as to reach the point on the surface of the 
foetal cranium through which the axis of the brim may be presumed to 
pass, we shall find that this corresponds to some point in the line of the 
sagittal suture, nearer to one or other fontanelle in proportion to the 
degree of flexion. 

The descent of the head is not, in the first part of its course, in a 
direction which is identical with what has been described as the axis of 
the pelvic canal. Its movement is, in fact, directly downwards and back- 
wards in the axis of the brim, until it approaches the floor of the pelvis, 
and experiences the resistance to its advance arising from the gradual 
approximation of the ischial planes. Upon the degree of flexion depends 
entirely the extent to which the occiput is in advance of the forehead. 
The further dilatation of the os uteri, and the rupture of the membranes, 
now usually admit of more exact observation by the finger, by which the 

- • This is one of the points upon which Naegele founded his belief in the existence 
of bi-parietal obliquity. Our reasons for dissenting from this view are fully given in 
the Appendix. 



284 THE MECHANISM OF LABOR. 

sagittal suture will be found traversing the pelvis obliquely in the right 
oblique diameter. In the posture in which the woman is when lying on 
her left side, we trace this suture downwards and forwards for a short 
distance, to a point within easy reach of the finger, where it divides into 
two branches. This indicates the posterior fontanelle, which the pressure 
generally renders indistinguishable as a fontanelle by approximation and 
overlapping of the bones. The two branches are the lambdoidal suture. 
Following the sagittal suture in the contrary direction, and with reference 
still to the posture of the patient, the finger travels upwards and back- 
wards towards the right sacro-iliac synchondrosis. It requires some 
effort to reach the anterior fontanelle, not only on account of its being 
situated posteriorly in the pelvis, but on account of the flexion, which 
removes it farther from our reach. Very generally, it can only be 
reached by subjecting the woman to some pain ; but it is easily recog- 
nized by its size and shape, and by the four sutures which run into it. 
If the right ear can be reached behind the symphysis without causing 
unnecessary suffering, the direction of its lobe at once reveals the posi- 
tion of the head. 

In consequence chiefly of the approximation of the sides of the pelvis 
which has been mentioned, the head now undergoes a change in its po- 
sition. This is effected by the movement first described by Smellie, 
which is known as the Rotation of the head. This rotation, which is 
effected gradually, brings the antero-posterior diameter of the head 
into, or nearly into, the conjugate of the pelvis, so that the occiput looks 
forward to the sub-pubic angle, and the forehead backwards to the hol- 
low of the sacrum. The recession of the anterior lip of the os beyond 
the advancing head admits of an easy examination of this process, which 
an observer may demonstrate for his own satisfaction by keeping his 
finger for a time in contact with the head. As he does so, he will often 
observe, as the head advances and recedes with successive pains, that 
the degree of rotation is greatest at the height of a pain, while, as the 
pain passes off, the head resumes its former position. The movement 
may thus be compared to that of a screw, the action of which is alter- 
nately direct and reversed. That nature provides for this rotation of 
the head in labor is made manifest by an examination of the relative 
measurements of the brim, cavity, and outlet of the pelvis. A question 
which has given occasion for much speculation is the mechanical cause of 
the rotation. The head, if maintaining its original direction, would sim- 
ply be arrested at the outlet of the pelvis, its further progress, if of 
average size, being impossible. In virtue of what law, then, does it so 
invariably rotate? 

Some of the older writers professed to recognize in the womb itself a 
rotatory power (^vis vartens)^ by means of which the rotation of Smellie 
was effected. Others have studied most industriously the mode of action 
of the various muscles which line the pelvis, believing that in this direc- 
tion the solution of the problem is to be found ; and by one accoucheur 
of eminence — Flamand of Strassburg — it was supposed that the action of 
the obturator internus and pyriformis muscles was the cause upon which 
the phenomenon in question depends. Modern investigation has, how- 



ROT.ATION. 



285 



Fig. 106. 




Internal Lateral Surface of Pelvis 



ever, proved that it is due to the nature 
of the opposing force which exists at 
the floor of the pelvis. If we look at 
the internal lateral surface of the pelvic 
cavity, as it is here represented, we 
observe that the tip of the ischial spine 
is the point which encroaches farthest 
upon the transverse measurement of 
the pelvic canal. The head, therefore, 
as it descends in the right oblique 
diameter, in the position which we are 
now studying, arrives at the floor of 
the pelvis with the occiput in front of 
the left ischial spine, and, as a conse- 
quence, the forehead behind the right 
spine. Rotation backwards of the oc- 
ciput or forwards of the forehead is 
thus eifectually prevented. As the 
propulsive stage advances, the occiput 
is conducted downwards and forwards 
by the inclined plane formed by that 

portion of the ischium which is in front of and inferior to its spine, and 
by the obturator internus muscle ; while on the other side of the pelvis, 
and on a higher level, the forehead is directed by the yielding sacro- 
sciatic ligaments towards the hollow of the sacrum. These two surfaces, 
then, are inclined planes which constitute the female screw, while the 
male screw is represented by the child's head; and we fully agree with 
Dr. Tyler Smith, that "the key to the pelvic mechanism, in an obstetric 
sense, may be said to be the spinous processes of the ischia." Some 
writers, it may be here observed, describe a posterior inclined plane of 
the ischium, which is separated from the anterior by an imaginary line 
leading from the spine of the ischium in the direction of the ilio-pectineal 
eminence. (See Fig. 15, p. 48.) This they suppose to act, in reference 
to the forehead, as the anterior plane does with the occiput. IS'o such 
action can, however, be performed by this plane, as the forehead im- 
pinges upon the spine and margin of the great notch, and is at once 
conducted to the li^ziaments alono; which it o-lides. 

We have already used the term " Presentation" in its broader signifi- 
cation. There is, however, another sense, in which it is employed by all 
British and American obstetricians, which here calls for some special 
notice, as there unfortunately obtains, in regard to this, as well as other 
terms in English midwifery, the objection that . each writer is left to 
attach to it his own meaning. The Presentation, in the second and more 
limited sense, is not the part of the child but the actual " point" on its 
surface which presents : and, if it be wished to express this correctly, 
we do not know of a more accurate definition of the term than that given 
by Professor Hodge of Philadelphia, who describes it as " that portion 
of the foetal ellipse which is recognized toward the centre of the canal 
of the pelvis and vagina." This is practically the same as that of Dr. 
Matthews Duncan — " that point on the surface of the child's head through 



286 



THE MECHANISM OF LABOR. 




which the axis of the developed pelvic canal passes." But, while admit- 
ting these to be mathematically more correct, we must own to preference 
for the meaning which is attached to the word by Dr. Tyler Smith, who 

defines it as that " portion of the foetal 
^i^- l*^*^- head felt most prominently within 

the circle of the os uteri, the va- 
gina, and the ostium vaginae, in the 
successive stages of labor." 

When the dilatation of the os 
uteri proceeds with unusual slowness, 
owing to rigidity, or premature rup- 
ture of the membranes, the caput 
succedaneum forms upon the scalp. 
Under such circumstances, that swell- 
ing will be found to occupy alto- 
gether or mainly, the right parietal 
bone. This is, however, no evidence 
of bi-parietal obliquity, as the swell- 
ing occurs in obedience to the laws 
of gravity, in the direction of the 
vagina, where the resistance is least. 
It is only, however, under circum- 
stances of exceptional resistance, that the swelling alluded to becomes 
developed at this stage. 

While the head is undergoing the rotatory process above described, no 
change whatever takes place in the parallelism which exists between its 
transverse diameter and the plane of the brim. With reference to the 
cavity of the pelvis, the right side is certainly lower, but this is a very 
different matter from what is asserted by the followers of Naegele.^ So 
soon as a certain amount of rotation has occurred, the vertex descends 
quite to the floor of the pelvis. The head now becomes exposed to a 
new set of forces in addition to those which have, up to this time, been 
the sole cause of its movements. The tissues which form the floor of the 
pelvis, although they yield, to some extent, before the advance of the 
head, constitute by their resiliency an opposing force which, Avhile it 
effectually bars the further advance of the head in that direction, deter- 
mines a motion which is the resultant of this and the force from above, 
and being intermediate in its direction between these, is consequently 
downwards and forwards. Solayres called this a reflected force, and 
describes the mechanism in the following graphic terms : "Hujus motus 

^ This is roughly indicated in the diagram here given. Fig. 107 shows the great 
amount of lateral obliquity, in reference to the horizon, of the head advancing in 
the first position in the axis of the brim, the centre of the sagittal suture being ex- 
actly midway between the promontory of the sacrum and the symphysis pubis. It 
shows, also, how, during the whole of this stage of labor, the right parietal protu- 
berance may be described, in general terms, as the part which first meets the finger, 
or as lowest in the pelvis, advancing, as it does, in the direction of the dotted line, 
parallel to the axis of the brim. If the head were in the transverse position, the 
sinking of the parietal protuberance would be still more decided. 

A B. The plane of the brim, meeting the horizon at an angle of 60O at A. 

CD. The axis of the brim, passing through the centre of the sagittal suture and 
the coccyx, and meeting the horizon at Z), at an angle of 30O. 



BIRTH OF THE HEAD. 287 

rationem baud immerito contuleris cum ea, quae nucleus prementes digitos 
fugit." An illustration of this is familiar to every schoolboy who has 
propelled a cherry-stone fresh from the fruit, by pressing it between his 
fingers. 

As the forehead of the child has, in its course along the back part of 
the cavity, to traverse a curve which is of much greater extent than the 
posterior surface of the pubis, w^e would anticipate what actually does 
take place — viz., that the chin, before the completion of the movement 
of rotation, leaves the sternum, and that the anterior pole of the occipito- 
frontal diameter descends, as regards the brim- plane, considerably in 
advance of the other — this motion being again reversed, at a more 
advanced stage, as we shall see presently. The successive changes 
which thus occur in the obliquity of the long diameter are well expressed 
by Dr. Murphy, when he says that the head may, in the course of labor, 
be described as " oscillating on its transverse measurement." 

From the time at which the head comes under the influence of the 
reflected force of Solayres, its general direction is altered, and now 
corresponds pretty closely with the axis of the vagina. The vagina, or 
what, in its altered anatomical relations, we may more appropriately call 
the lower portion of the parturient canal, has a curve for its axis, which 
we have already demonstrated as continuous with the axis of the bony 
pelvis. (See Fig. 14.) The general direction of this is downwards 
and forwards, so that the head may be assumed now to move in a direc- 
tion which forms an approach to a right angle with its original course. 
The pressure of the head upon the perineum gradually effects the dilata- 
tion of the terminal portion of the canal. The left division of the os 
frontis, in the immediate vicinity of the fontanelle, or the contiguous 
portion of the parietal bone, presses upon the coccyx, which moves back- 
wards to the extent of an inch, in order to permit of the passage of the 
child. If the pelvis is at all under the average in point of size, the fore- 
head is arrested at the apex of the sacrum, and the occipital end of the 
lever is again driven downwards, so as to press upon and distend the 
perineum. If, however, the parts be ample, and the perineum not unduly 
resistant, this does not occur, and the whole bulk of the head follows the 
curve of the sacrum at every pain, obviously attempting to effect an exit 
immediately under the pubic arch. 

From the above description, it is apparent that the occipito-mental or 
longest diameter of the child's head is never at any time thrown across 
the pelvis. The moment now approaches, however, at which a new move- 
ment must be executed, that of extension, and it is difficult at first to see 
how this can be effected without the extreme diameter being turned into 
the conjugate of the outlet. Nature fortunately does not attempt this 
movement until the occiput is passing upwards in front of the symphysis 
pubis in the act of birth. The motion of extension is the reverse of the 
flexion which has been mentioned as one of the earlier mechanical phe- 
nomena of labor. The oscillations which the head in its course under- 
goes on its transverse axis are — first, flexion ; then partial extension prior 
to rotation ; then flexion, if the forehead be arrested at the apex of the 
sacrum ; and finally, the movement of exaggerated extension, which is 
only completed with the birth of the head. The occipito-mental diameter 



288 THE MECHANISM OF LABOR. 

is not at any moment thrown across, and is only released when its occi- 
pital pole is born. The occiput, vertex, forehead, face, and chin suc- 
cessively sweep over the distended perineum, the head continuing its 
curved axis of motion, and being born upwards and forwards in front of 
the mons veneris. 

Before Naegele wrote, it was universally believed that the head was 
born with its antero-posterior measurement accurately corresponding to 
the conjugate diameter of the outlet. A considerable number of modern 
obstetricians still hold this view, and it is certain that, in a large number 
of instances, the head is so born. The Heidelberg professor taught, 
however, that the head did not pass into the W'Orld after this fashion, but 
that there existed at the outlet a certain amount of pelvic obliquity, as 
the forehead did not rotate altogether into the sacrum ; and he showed, 
in addition, that a certain degree of bi-parietal obliquity is maintained, 
according to which the right parietal protuberance is, in the first position, 
born in advance of the left, so that the caput succedaneum is at this stage 
formed upon the superior and posterior quarter of the right parietal bone, 
close to the posterior fontanelle. That both of these obhquities gene- 
rally occur, in what we may call a typical case of normal parts and mode- 
rate perineal resistance, we believe ; but, in asserting that they are 
essential phenomena, such as are the movements of Flexion, Rotation, 
and Extension, the celebrated author committed an error which his fol- 
lowers have but too faithfully copied. For these obliquities are of com- 
paratively trifling importance, and should never have been bracketed with 
the other and really important movements. Until he has fully mastered 
the latter, w^e should advise the student to take no note of these obliqui- 
ties. The most recent writers on the subject (Kiineke, Hodge, and Dun- 
can) all dispute the conclusions of Naegele and argue in favor of the 
parallelism, or, as they term it, " Synclitism," of the bi-parietal and 
cervico-bregmatic planes of the child's head, with the planes of the pelvis 
and the vagina. With reference to the observations of Professor Hodge, 
it may be remarked that he, his celebrated predecessor, Dewees, and, we 
may add, the American obstetrical school generally, have long repudiated 
many of the doctrines of Naegele w4iich are still taught in English text- 
books. Fig. 108 shows the relation which the head, when about to pass 
in this position, bears to the pelvic structures. 

No sooner is the head born than (with certain exceptions to be noticed 
presently) another rotation takes place, — the face of the child turning 
spontaneously to the right thigh of the mother. This is due to the man- 
ner in which the shoulders descend. In Fig. 109 we are looking down- 
wards into the cavity of the uterus. It will be observed that the broad, 
or transverse, diameter of the shoulders and of the breech occupies the 
left or opposite oblique diameter to that in which the antero-posterior 
measurement of the head is descending. Upon the birth of the head, 
the shoulders encounter the same difficulty from the ischial spines ; and, 
as the rotation must be such as to bring the anterior shoulder, as it did 
the occiput, under the pubic arch, the left, or posterior shoulder revolves 
into the hollow of the sacrum. This movement of the shoulders takes 
place, therefore, in a direction which is the reverse of the previous rota- 
tion of the head ; so that we may with perfect propriety, look upon the 



RESTITUTION 



289 



head as resuming the oblique position which it originally held in reference 
to the pelvis. It has, on this account, been well called the movement of 
Restitution. 



Fiff. 108. 



Fiff. 109. 




The Head approaching the Outlet 
Position. 



een from above. (Schaltze.) 



There is another phenomenon which should not here be overlooked, 
inasmuch as it exercises no inconsiderable influence on the progress of 
labor. This is the moulding, of which the head is susceptible, without 
any risk to the child. The amount of moulding is, of course, propor- 
tionate in a great measure to the resistance, but the head, when born, 
presents, in every instance, a shape Avhich gives it a peculiar elongated 
appearance, and, in cases where the caput succedaneum is much devel- 
oped, this is still further exaggerated. The moulding and pointing of 
the occipital region is the Hinterliauptspitze of the Germans ; and the 
form presented is, as will be shown in the sequel, very diiferent from 
that which is produced in occipito- posterior positions. As soon as the 
shoulders have escaped, the mechanical difficulties of delivery may be 
said to have terminated ; for the extent to which the parts have been 
dilated during the birth of the head will have rendered them more than 
sufficient for the egress of the parts which remain. 

We have, in the above description of the first position, gone pretty 
fully into detail, in order that the other three positions may be more 
easily understood. We would recommend the student, before attempt- 
ing any practical investigation of the facts which have been set forth, to 
follow the description with the bones in his hand, — by which means only 
can he thoroughly understand the subject, to the extent which is essential 
as a preliminary to the intelligent examination of the phenomena of actual 
labor. 

19 



290 



THE MECHANISM OF LABOR. 



The figure here shown indicates, diagrammatically, the various posi- 
tions which the child occupies during the successive stages of labor, as 



Fig. 110. 




Diagrammatic Representation of Successive Stages of the Fi'st Position. 

just described. The representation is supposed to be of a woman from 
whose body the right half has been removed, leaving the foetus alone 
untouched. 

Second Position. — This is, in one sense at least, the converse of the 
First. As the head enters the brim of the pelvis, the occiput is turned 



Fi-. 111. 




Second C'rauial Position. 



towards the right ilio-pectineal eminence, the forehead being directed to 
the left sacro- iliac synchondrosis. This, therefore, like the first, is an 



SECOND CRANIAL POSITION. 



291 



occipito-anterior position, the only difference being that it occupies the 
left oblique diameter instead of the right. It is the left side of the head 
which presents, and the neighborhood of the left parietal protuberance 
is, therefore, the part which the finger first reaches in a digital exami- 
nation. The sagittal suture corresponds to the left oblique diameter, so 
that, when the woman is on her left side, the finger passes upwards and 
for\Yards, to reach the posterior fontanelle, and downwards and back- 
wards to reach the anterior. The occipital pole of the antero-posterior 
diameter of the child's head is, as 

in the first position, driven down- ^^S- 112. 

wards in advance of the other. It 
glides, during the rotation which 
succeeds, in a direction downwards 
and forwards, along the ischial plane 
on the right side, towards the sub- 
pubic arch, while the forehead moves 
from left to right, along the left 
sacro-sciatic ligaments, towards the 
hollow of the sacrum. The head, 
after complete rotation and sufficient 
distension of the perineum, ap- 
proaches the orifice of the parturient 
canal, in a position which generally 
approaches that shown in the an- 
nexed figure (Fig. 112), in which 
a certain amount of left obliquity 
still exists, and the left parietal pro- 
tuberance is a little in advance. The 
face, upon its birth, turns towards 
the left thigh of the mother, while 

the shoulders, after passing the brim in the right oblique diameter, are 
rotating so as to bring the left shoulder under the pubic arch. 

With reference to this external rotation of the head, it must here be 
remarked, — and the observation applies equally to first and second posi- 
tions, — that the rotation described, in each case, while the rule, is a rule 
which admits of exceptions. It is, no doubt, true, that an observation of 
the external rotation of the head may generally be received as evidence 
— confirmatory, or the reverse — of the diagnosis which we may previously 
have formed as to its position in the pelvis. But this is by no means 
invariable, as sometimes, in undoubted first positions, the face rotates to 
the left, and in second, to the right ; the direction of the movement in 
each of these cases being a continuation, by the shoulders, of the same 
screw motion previously performed within the pelvis by the head. Oc- 
casionally, as Naegele admits, and probably in cases where the diameters 
are greater than usual, the shoulders pass in the transverse diameter, 
and there is no rotation at all ; while in cases rarer still, as is described 
by Schmitt, " the face of the born head turns itself, first to the one side 
and then to the other, as if to ask of nature in what direction the descent 
of the shoulders could best take place." 

Once more let us recapitulate the various movements which the head 




Second C:ani;il Pu.siaoii at the Outlet 



292 THE MECHANISM OF LABOR. 

undergoes in the two Occipito-Anterior positions above described, and 
note very briefly their mode of action as mechanical aids to labor : — 

The general direction followed by the head of the child from the brim 
to the floor of the pelvis, is that of the axis of the brim. The long 
diameter of the oval formed by the head occupies one or other oblique 
diameter, as it finds in these the longest measurement. 

By the antero-postorior obliquity of the head, not only is the occipito- 
mental diameter prevented from lying, by any possibility, across the 
pelvis, but the occipital pole of the occipito-frontal is so depressed that a 
further and obvious mechanical advantage is gained. This is otherwise 
called Flexion of the head. 

Rotation is a movement of the head upon its perpendicular axis, accord- 
ing to which its longer diameters are moved into, or nearly into the con- 
jugate of the pelvis, which is at this stage the most ample. This is 
mainly eff'ected by the anterior ischial planes, and the yielding of the 
sacro-sciatic ligaments. 

The movement of extension is that which occurs' at the moment of 
birth, its most important object being to admit of the passage of the great 
occipito-mental diameter without injury to the perineum. It is, like 
flexion, a movement of the head on its transverse diameter. The chin 
leaves the sternum of the child as it descends. through the pelvis, a cer- 
tain amount of flexion again occurring if there is much resistance at the 
apex of the sacrum, but it is only when its head is passing the external 
parts that the exaggerated movement occurs to which the name Extension 
has par excellence been given. The general direction of the movement, 
from the time the head reaches the floor of the pelvis, is downwards and 
forwards, but the head follows the parabolic curve of the axis of the 
passage. 

The obliquity (pelvic) of the head at the outlet is probably due to 
the position of the shoulders; the bi-parietal obliquity is accounted for 
by the head still retaining something of its original parallelism to the 
plane of the brim. Neither is of much importance, but the latter, by 
permitting one parietal protuberance to precede the other, diminishes, to 
a slight degree, the circumferential measurement of the ostium vaginge at 
the moment of its greatest distension. 

The external rotation of the head is caused by the rotation of the 
shoulders in the opposite oblique diameter to that which was occupied 
by the head. As the result of this is to restore the head, by a move- 
ment on its perpendicular axis, to its original position, it has been called 
the movement of Restitution. 



THIRD CRANIAL POSITION. 293 



CHAPTEK XVIII. 

MECHANISM OF LABOR— (CoxXTixued). 

Ocvipito-Posterior Positions. — Third Position ; rotates into the Second, or may 
terminate unth Forehead forwards. — Fourth Position ; rotates into the First, 
or may terminate with Forehead forwards. — Artificial Rectification of these 
Positions. — Comparative Frequency of the Four Cranial Positions. 

Face Presentations.— Z>^^s^^;?c•^^o?^ hetween '•'■ Obstetric aV and '■'■AnatomicaV 
Face. — Mento-Posterior and Mento- Anterior Varieties — Fourth Position: 
mechanism of. — Third Position, — First Position ; rotates into the Fourth. 
— Second Position; rotates into the Third. — Relative Frequency of Facial 
Positions. — Operative Interference in. — Irregular Presentations. — J'ahular 
Comparison of Cranial and Facial Positions. 

In the two remaining or Occipi to-Posterior positions the head lies, as 
in the Occipito-Anterior, in one or other of the oblique diameters, so 
soon as it fully occupies the brim. The reversal, however, of the frontal 
and occipital poles of the long diameter of the head here renders neces- 
sary the application of mechanical principles, which in some respects 
differ very widely from those which have been explained as accounting 
for the phenomena attendant upon delivery in the occipi to- anterior posi- 
tions. This becomes to some extent obvious upon an examination of the 
cranium itself, and by a comparison of the broad unyielding forehead 
with the pointed compressible occiput. But, if we observe further the 
relation which the pelvic cavity bears to possible movements of flexion 
and rotation, it will at once become apparent that in these positions 
nature has difficulties to overcome in comparison with which those at- 
tending the occipito-anterior positions are probably trifling. What these 
special difficulties are, we shall attempt to show, noting carefully, at the 
same time, the means which nature adopts to overcome the impediments 
which thus arise. 

Third Position. — The head in this case enters the brim of the pelvis 
in the right oblique diameter, with the forehead turned towards the left 
ilio-pectineal eminence and the occiput to the right sacro-iliac synchon- 
drosis, as shown in the following figure. On a digital examination, it 
is the left parietal bone which the finger touches, in the neighborhood 
of its protuberance, at a point usually a little anterior to that reached in 
the second occipito-anterior position. With reference to the posture of 
the woman, the sagittal suture is traced downwards and forwards, where 
it ends in the large lozenge-shaped anterior fontanelle ; while, in the 
contrary direction, it may be followed upwards and backwards, ter- 
minating in the posterior fontanelle. This point is here of paramount 
importance in the diagnosis, for when, in any case, we find that the 
great fontanelle is within easy reach of the examining finger, our sus- 



294 



THE MECHANISM OF LABOR. 



picions should at once be excited, and the nature of the position carefully 
ascertained. 

So soon as the head becomes engaged in the brim, one of two things 
maj occur. In the one case, the occiput is driven, by the propulsive 



Fiff. 113. 




Third Ciuuial Position. 



force communicated through the spinal column, downwards in advance of 
the forehead, as in occipito-anterior cases ; in the other, the occiput is 
arrested, and the force being thus transferred to the frontal pole of the 
long diameter of the head, that pole precedes the other in its descent. 
Whether the forehead or the occiput thus descends, there is, in the great 
majority of cases, no barrier to the termination of the labor by the 
unaided efforts of nature, although such cases are more or less pro- 
tracted. When the head, therefore, is placed in the third position, the 
labor may terminate in two ways, either by rotation into the second 
position or by the forehead passing under the pubis. As the former is 
the rule, and the latter a rare exception, we shall first consider the 
mechanism according to which, in the great majority of cases, such 
labors terminate. 

The natural termination of the third position is by a movement which 
in extent far exceeds the ordinary rotation of the head. The facility 
with which this occurs depends in no small measure upon the capacity of 
the pelvis. For nothing is more essential, as a preliminary to this move- 
ment, than an easy descent of the occiput in the direction of the right 
sacro-sciatic ligaments ; whereas, any difficulty which may exist, from 
peculiar formation, or contraction of any of the diameters, by arresting 
this initiatory movement, favors the descent of the forehead. The more 
marked the flexion of the head, therefore, and the nearer the posterior 
fontanelle to the examining finger, the greater is the confidence Avith 
which we anticipate a natural and satisfactory rotation. If, as is fre- 
quently the case, the head descends quite to the floor of the pelvis before 
rotation has occurred, depression of the occiput and corresponding reces- 
sion of the forehead are still the signs which point towards rotation. 
For, in this situation, the forehead, which occupies the anterior inclined 
plane of the ischium on the left side, cannot, on account of the approxi- 
mation of the ischial spines, rotate directly in the same pelvic plane. It 



THIRD CRANIAL POSITION. 295 

is essential, therefore, that the forehead should be elevated above the 
spine of the ischium, and the antero-posterior diameter of the head thus 
shortened in reference to the pelvic planes. This is precisely what is 
eifected by flexion at this stage ; and, if we watch the process with the 
finger, we observe, in the first instance, that the anterior fontanelle re- 
cedes from our finger in the direction of the horizontal ramus of the 
pubis. The posterior fontanelle descends and comes within easy reach, 
until the flexion is so complete that the occipito-mental diameter ap- 
proaches the axis of the brim. A rotatory or screw motion of the head 
now becomes manifest, the forehead moving upwards and backwards on 
the left, and the occiput downwards and forwards on the right side of the 
pelvis during a pain ; and the head resuming its former position during 
the interval. Presently, and often in the course of a single pain, it per- 
forms a rotation equal in extent to the quadrant of a circle ; and, if we 
now make an examination, we find that the head occupies what was 
described in the last chapter as the second cranial position. In its 
normal and natural course, therefore, the third jjosition rotates into the 
second. 

The rotation thus efl'ected is remarkable not only in regard to the 
extent, but also in respect of the mechanism by which it is eifected. If 
the mechanism were identical with what obtains in the occipito-anterior 
varieties, the forehead would, in every case, be directed by the ischial 
spine over the left ischio-pubic ramus towards the sub-pubic arch. But 
the mechanical result of pressure transmitted through the vertebral 
column is the same in all cases where the pelvic resistance is equal on 
all sides. The occiput being thus pressed down, the forehead rises as 
has been described, and the chin is approximated to the sternum. A 
point is presently reached at which the whole forehead has risen above 
the level of the ischial spine, and the rotatory movement commences. 
The occiput, on the other side, is beneath the right spine, and approaches 
the centre of the pelvis, being directed downwards and forwards, on the 
right side, by the corresponding margin of the sacrum and coccyx, and 
the sacro- sciatic ligaments. This is probably the cause of the first eff'ort 
at rotation, but as soon as the forehead passes sufficiently far back to 
impinge upon the posterior ischial plane, it at once glides along this to 
the left sacro-iliac synchondrosis, and the rotation is complete. After- 
wards — the presenting point being as before a portion of the left parietal 
bone — the case goes on as if it had been from the first a second position, 
the only difference as effecting the progress of the labor being that that 
process has now to commence, should it be required, which consists in 
moulding of the hindhead, and Avhich, under other circumstances, would 
already have been effected. From what has been said, it will be under- 
stood that the earlier and the more easy is the descent of the occiput, 
the more uninterrupted and satisfactory is the course of the labor ; in 
such cases there is in fact no special difficulty, and no additional danger 
to either mother or child. But, in cases in Avhich the forehead continues 
to descend, the difficulty of rotation is greatly enhanced, for in that case 
the preliminary flexion involves the necessity of the occipito-frontal 
diameter being thrown across the pelvis ; and if the measurements gene- 
rally are small, this can only be eff'ected with considerable difficulty, a 



296 



THE MECHANISM OF LABOR, 



difficulty which is increased by a certain degree of moulding, and the 
formation of the caput succedaneum in an unusual situation. But even 
these cases will usually terminate as second positions, more especially if 
a certain amount of assistance be afforded in a manner to be hereafter 
described. 

In a small proportion of cases, but certainly much more frequently 
than Naegele and his followers would have us suppose, the rotation 
above described does not take place. The forehead, in these instances, 
sinks lower and lower in the pelvis, and the anterior fontanelle ap- 
proaches still more closely to the ostium vaginse. A very useful practi- 
cal distinction was drawn by the late Dr. Uvedale West, of Alford, a 
veteran practitioner who devoted much earnest thought to the subject 
now in question. Dr. West, recognizing the flexion of the head as an 
essential element in rotation, proposed that those cases in which the frontal 
pole of the long diameter remains high, all of which end by rotation, 
should be called hregmato- cotyloid^ while the others which terminate, or 
threaten to terminate, with the forehead forwards, should be designated 
fr onto- cotyloid — ^a simple distinction of unmistakable importance. 

When the head assumes this fronto-cotyloid position in a well-marked 
degree, w^e may be pretty sure that it will end with the forehead for- 
wards instead of the occiput. But we must not too hastily adopt this 
conclusion, as cases have been observed in which, at the last moment, 
when the part presenting had already shown itself at the external aper- 




Fronto-Anterior Termination of the Third Position. 



ture, the forehead spontaneously moved up, and delivery was effected, 
after rotation, in the usual way. The attention of the accoucheur, 



FOURTH CRANIAL POSITION. 297 

should he have omitted to notice it previously, may be attracted by the 
fact that the labor is progressing in an unsatisfactory manner, and that 
the progress made is quite out of proportion to the expulsive force ; and, 
on examination, he now recognizes the nature of the case with which he 
has to deal. At this time, the orbits and nose may be easily felt behind 
the pubis, and as labor progresses the forehead comes into view. Ca- 
zeaux says that the superciliary arch may sometimes be seen, and that 
on one occasion he saw the upper eyelid. Under the influence of power- 
ful uterine contraction, the occiput is now^ driven downwards, the head 
executing thus tardily its movement of flexion. The perineum becomes 
distended to a dangerous extent by the posterior part of the head. This 
cannot be relieved, as in the ordinary position, by the movement forward 
of the occiput, to which the forehead offers no resemblance in shape. 
The presenting part moves, therefore, somewhat upwards, and to the 
left, until the occiput passes over the strongly distended perineum. The 
final movement is periormed by an extension of the head — the nape of 
the neck, pressed against the anterior margin of the perineum, being the 
centre upon which the revolution occurs which brings the forehead, nose, 
mouth, and chin, successively from beneath the pubic arch. The motion 
at this point is precisely analogous to what obtains in first and second 
positions, where the centre of the motion is the sub-pubic angle, and the 
forehead and face sweep forward over the perineum. There is certainly 
in all such cases an increased risk of perineal laceration. The various 
stages in the mechanism of delivery in this position are shown in the 
accompanying diagram. (Fig. 114:.) 

Another possible termination of occipito-posterior positions consists in 
a continued moveaient of extension, or rotation of the head on its trans- 
verse axis, by which the case is changed into a presentation of the face. 
And, moreover, as a rotation such as this would bring the chin forwards 
— which is, as we shall show, in a face presentation, a quite favorable 
position — ^we may assume that such an occurrence would be rather a 
favorable termination than otherwise to the cases Avhich Dr. AVest terms 
fronto-eotyloid. 

Fourth Position. — The head, in this position, enters the brim of the 
pelvis in the left oblique diameter. The forehead is turned towards the 
right ileo-pectineal eminence, and the occiput to the left sacro-iliac syn- 
chondrosis, as shown in Fig. 115. On a digital examination, it is the 
right side of the head which the finger touches. The sagittal suture, in 
reference to the posture of the woman, is traced downwards and back- 
wards to where it terminates in the posterior fontanelle, while, in the 
contrary direction, the finger follows it upwards and forwards to the 
anterior fontanelle. The opinion is very generally entertained that, in 
the fourth position, the engagement of the head is more difficult, and its 
rotation slower than the third. It is impossible to avoid the conclusion 
that this is due, in a great measure, if not entirely, to the rectum, which, 
by encroaching upon the left diameter, renders it less capacious than the 
right. The fourth position being the converse of the third as the second 
is of the first, we find the description of the one will serve, mutatis ma- 
tandis — reading right for left, and so forth — in every respect for the 
other. It may thus terminate in two ways, according as the occiput or 



298 



THE MECHANISM OF LABOR. 



the forehead descends. In the former case, the occiput passes below the 
left, and the forehead above the right ischial spine, so that the fourth 
position rotates into the first in the natural and normal course of such a 
case, and ends with the occiput under the pubic arch as usual, the right 

Fig. 115. 




Fourth Cranial Position. 

side of the head thus beiuT, during the whole course of the labor, the 
lowest in the pelvis. In this, as in the third position, a certain number 
of cases terminate with the forehead under the pubis, the mechanism, in 
each case, being precisely similar, the occiput usually passing over the 

fourchette, whereupon the forehead, 
^ig- ^16- nose, and chin sweep successively, 

backwards and downwards, from be- 
hind the pubic symphysis. The 
position of the foetal head in refer- 
ence to the outlet of the pelvis is 
shown in the enorravins;. If we 
admit the possibility of conversion 
of a third position into a face case 
by rotation on the transverse axis of 
the head, we must also admit it in the 
case of the fourth position. ' And it 
is woi'th noticing that such a rotation 
would directly, and without further 
change, convert the position which 
we are now speaking of into that 
position of the face which is most 
frequent in its occurrence. In all 
cases in which the forehead is born 
forwards, the ordinary process of 
moulding is reversed, and the head 
presents a very remarkable appear- 
ance, owing to the flattening of the occipital, and bulging of the frontal 
regions. 

The comparative difficulty which arises from the situation of the rec- 
tum constitutes, therefore, as it would seem, the only practical distinction 
between third and fourth positions. All observers seem to have agreed 




Fourth Cranial Position at the Outlet. 



OCCIPITO-POSTERIOR POSITION. 299 

in this — that, in the fourth, the rotation takes place as a rule, and pro- 
bably, on account of this very difficulty, on a higher level as regards the 
pelvis ; and that, if it descends to the floor of the pelvis with the forehead 
still directed towards the right obturator foramen, the chances of rotation 
at this more advanced stage are less than in the third. Rotation, at an 
early stage of labor, before it is yet practicable to ascertain the actual 
position of the head with anything like certainty, is probably of much 
more frequent occurrence than we have any idea of. Few things are 
more familiar to the experienced accoucheur than a rotatory or rolling 
movement of the head, which he observes either during a pain or an in- 
terval, while it is still high in the pelvis. This is due partly to uterine 
action, and partly to the movements of the foetus, and we have no doubt 
that, by this means, many unnatural and faulty positions are rectified 
even after labor has commenced; and we are further entitled to assume 
that in this way many occipito-posterior positions are rectified at such a 
stage that their detection is rendered impossible. It should always be 
remembered that the dorso- or occipito-anterior position of the child is 
the natural one, and that according to which the irregular oval which it 
forms is most conveniently disposed. 

Recognizing, as we now do, the natural termination of third and 
fourth cases as second and first respectively, a very important practical 
point arises, which may perhaps be most conveniently discussed at this 
place. This is the possibility of rectification by artificial means of 
occipito-posterior positions, which are about to terminate, or threaten to 
terminate, with the forehead towards the pubis. No possible doubt can 
exist as to the fact that the position of the head may be, and often has 
been, changed by the operations of the accoucheur. In confirmation of 
this assertion, we have the evidence of the most eminent obstetricians. 
More than a century ago, Smellie, after having repeatedly, but in vain, 
attempted to drag the head through in a case of this kind, bethought 
him of trying to turn the face backwards into the hollow of the sacrum. 
Success attended his first attempt — a result which '' gave him great 
joy," and opened his eyes to a new field of improvement "in the 
method of using the forceps in this position." Clarke, Burns, and 
others stated that rectification could be brought about in many cases 
by the use of the finger alone, and, among accoucheurs of our own day, 
Murphy and Uvedale West have emphatically expressed their views in 
favor of the feasibility of this proceeding. 

As regards the period of labor at which rectification may be effected, 
we find that many writers assume, or at least imply, that the operation 
may be performed at any stage. The fact is, however, that the head 
cannot in ordinary circumstances be rotated until it has reached that 
stage of the labor where nature, as a rule, spontaneously induces the 
rotation, so that it will often be a matter of difficulty to say what share 
in the movement we are to award to nature and what we may claim as 
the result of our operative interference. The conclusion with reference 
to the subject at which we have arrived is that we may succeed in amend- 
ing the position of the head in two class of cases. In the first of these, 
the head is free at the brim, or at least has not as yet encountered any 
serious pelvic resistance ; and here rotation may be effected by the for- 



300 THE MECHANISM OF LABOR. 

ceps in a manner which will be more particularly alluded to when we 
come to speak of the uses of that instrument. In the second class of 
cases referred to, the head has reached the floor of the pelvis, where we 
have natural rotatory forces operating in our aid ; but no attempt, while 
the head is in a situation intermediate between these two, is likely to be 
attended with success. 

The forceps is quite inapplicable, for the purpose of rotation, to the 
class of cases last mentioned, for reasons which are obvious. The surest 
and safest guidance is to be found in a careful study of the mechanism 
by which nature at this stage effects the rotation. And, if we do so, it 
will soon become apparent that it is only by imitating or assisting nature 
that we can hope for success. If we attempt simple rotation, the ischial 
spines interpose a barrier which it is impossible to surmount ; but if, on 
the other hand, we take nature for our guide, and assist her in the direc- 
tion which she indicates, Ave must employ our whole efforts in promoting 
the preliminary flexion of the head, which has been fully explained in 
the description of the third position. With this in view, then, we should 
press the forehead upwards, in the direction of the ilio-pectineal emi- 
nence, on the side in which it lies. This is done most eff'ectively by 
bringing two fingers to bear upon it and pressing in the direction indi- 
cated during a pain. This, in the first instance, will probably have little 
effect in displacing the forehead, but, if we can only succeed in prevent- 
ing its further descent, we thus transfer in some measure the propulsive 
force to the occiput, and in a greater or less degree encourage the essen- 
tial movement of flexion. After a time, the effect of this will probably 
become manifest in a recession of the frontal pole of the long diameter. 
But, should the effort fail, we may, as Dr. West suggests, attempt to pull 
down the occiput by means of the instrument called the vectis, while con- 
tinuing the pressure with the fingers as before. By one or other method, 
or by a combination of both, we may often succeed in effecting the natu- 
ral flexion of the head, until the forehead is high enough to pass above 
one ischial spine and the occiput low enough to pass beneath the other, 
when nature herself will effect the actual rotation, and may be left to 
complete the labor without any further interference. Madame Boivin 
seems to have entertained the belief that, in the third position, some- 
thing may be gained by emptying the rectum so as to facilitate rotation 
into the second ; and that, as regards the fourth, a distended rectum is 
rather an advantage than otherwise, inasmuch as it would tend to pre- 
vent the movement of the occiput into the hollow of the sacrum, and so 
indirectly encourage the rotation into the first position, which ^ye desire 
to promote. 

While the four positions which have now been described are all which 
we think it necessary to specify in detail, there can be little doubt that, 
under exceptional circumstances, others may be met with. The acci- 
dental position, for example, of the head in the conjugate or transverse 
diameters of the brim has, in the opinion of many approved authorities, 
warranted them in adding four more, making eight positions in all. We 
apprehend, however, that the mechanism, in such rare instances as may 
be met with of conjugate or transverse as primary positions, does not call 
for any special description, and that to admit them would be unnecessa- 



COMPARATIVE FREQUENCY OF CRANIAL POSITIONS. 



301 



rily to complicate a subject already beset with sufficient difficulties. Both 
of the positions indicated would, in a normal pelvis, inevitably be resolved 
into one or other of those which have been described, and would thus 
terminate according to the laws which we have attempted to elucidate ; 
while, if they were the result of abnormal disproportion of the parts, 
they would come under the influence of special laws, which it is no part 
of our object at present to explain. We take no notice, it will be ob- 
served, of premature birth or putridity of the foetus, in which the child 
may pass in any diameter ; but even here the tendency is to follow the 
natural course. 

"We have now to consider the subject of the Comparative Frequency 
of the cranial positions. It may be considered that this ought to have 
been referred to at a somewhat earlier stage. We have, however, pur- 
posely postponed it until now, as considerations arise, in reference to points 
not yet fully determined, which can only be understood by those who are 
in possession of the facts which have been detailed in this and the pre- 
ceding chapter. It is to be regretted that no inconsiderable differences 
of opinion, on many of the points referred to, have arisen in consequence 
of the views of Naegele having been implicity received, while yet they 
obviously lacked confirmation. 

From the time of Smellie, the first position has been universally ad- 
mitted as that which is by far the most frequent. Until the publication 
of Naegele's celebrated essay, there was a similar unanimity among ob- 
stetricians as to the second position being next in point of frequency to, 
and in all respects the converse of the first; but the effect of his researches 
upon the minds of all modern practitioners has been to modify greatly, 
and in most cases entirely overthrow, the conclusions of his predecessors 
on this point. In order to avoid a mass of statistical details, we shall 
only attempt here to compare the conclusions of Xaegele, and of those 
who agree with him, with the results attained by some modern observers 
who diff'er from him more or less widely. It is beyond doubt that his 
original doctrines are, to the present day, more fully believed in this 
country than in France, America, or even in Germany; and this is ob- 
viously due to the fact that many of our most eminent accoucheurs have 
taught and still teach these doctrines, while some believe that they have 
confirmed their accuracy by subsequent research. All this is shown in 
the following tabular analysis ; but it is therein further made evident that 
there are many men of undoubted talent and experience who decline to 
accept the evidence even of Naegele as of greater weight than that of 
their own senses. The following table shows the percentage of each of 
the four cranial positions, as deduced from the published statistics of the 
observers quoted: — 





First 


Second 


Third 


Fourth 


Xot 




position. 


position. 


position. 


position. 


classified. 


Naegele . 


, 70- 




29- 




1- 


Naegele, the younger 


; 64-64 


... 


32-88 


... 


2-47 


Simpson and Barrv . 


76-45 


•29 


22-68 


•58 


... 


Dubois . 


1 70-83 


2-87 


25-66 


-62 




Murphy . 


i 63-23 


16-18 


16-18 


4-42 


... 


Swayne . 


1 86-36 


9-79 


1-04 


2-8 


... 



802 THE MECHANISM OF LABOR. 

By means of this tabular arrangement, we see at a glance the extent 
to which, apparently, one observer differs from another, but we must look 
a little closer at the figures to discover their true import. In the first 
place, we may observe that the two Naegeles regarded the second and 
fourth positions as so exceptional that they did not include them at all in 
their system of classification, contenting themselves with the assertion 
that, when present, there were either some special circumstances which 
induced the irregularity, or that the observations were not made suffi- 
ciently early in the labor. The elder Naegele, indeed, says that, to 
positions of the third kind, those of the face come next in point of fre- 
quency, while the second is classed by him with the conjugate variety as 
rarest of all. The younger Naegele, again, who, while he enters into 
statistical details much more deeply, repeats and corroborates his father's 
doctrines, lays himself open in more than one place to criticism, in respect 
of the manner in which he disposes of his statistics to suit his own views. 
He states, for example, that his conclusions are based on 3T95 cases of 
cranial presentation, but instead of placing these fairly under the four 
heads which constituted essentially the classification of the German school, 
he boldly says : "After deducting 94 cases, in which the original position 
of the head could not be made out on account of various circumstances, 
we have 3701 carefully observed cases of cranial presentation." Now, 
these 94 cases form nearly two and a half per cent, of the whole, and if 
divided, as we cannot doubt they ought to have been, between the posi- 
tions numbered second and fourth, would have brought the statistics of 
Naegele very near to those of Dubois, whose observations accord perhaps 
as closely as those of any other with the prevailing ideas of the present 
day. 

The statistics of Simpson and Barry confirm the conclusions of Nae- 
gele more closely than any others ; but, it will be observed that a certain 
percentage of second and fourth presentations is admitted, which becomes 
more marked in the figures of Dubois. 

The conclusions arrived at by the two observers whose names are 
placed last upon the list, indicate a startling discrepancy with the results 
given above, and are of themselves sufficient to show that the doctrines 
of Naegele are by no means definitely settled. Dr. Murphy's conclu- 
sions are the result of a careful personal observation, in the Dublin 
Lying-in Hospital, of sixty-eight cases of cranial presentations, in which 
he found the second position to occur as frequently as the third. His 
conclusions may at first seem to be less satisfactory than if they had been 
based upon a larger number of observations; but, at the same time, we 
must admit that the results obtained by so able and experienced an ac- 
coucheur as Dr. Murphy, should be held as more likely to be correct 
than when the observations on which statistics are founded are intrusted 
in a great measure to others. The experience of Dr. Swayne shows a 
larger number of cases of first position than any other observer, and in 
other respects his deductions are still more strikingly opposed to the idea 
generally received. Reverting to the opinion held before Naegele, he 
believes that in point of frequency the second comes after the first, and 
that the fourth is more frequent than the third, an opinion in which he is 
supported by Professor Millar of Louisville. In the table above given 



STATISTICS OF CRANIAL POSITIONS. 303 

■\ve have avoided extremes, or we could have given statistics which have 
been offered in proof of assertions which are, as regards the views of 
Naegele, more contradictory still. 

In attempting to reconcile statements so conflicting, we cannot fail to 
become convinced of the fact that, even in the most experienced hands, it 
is no easy matter to determine the position of the head in the early stage 
of labor. It is not to be conceived that all the observers above quoted 
can be right. It is equally clear that nature must have some law, ac- 
cording to which the head of the child enters and passes through the 
pelvis of the mother. But is it in our power to determine what is the 
law of nature, and in what this or that observer has erred ? Can we so 
reduce the law to statistical results, as to place the matter for ever on 
the basis of irrefragable evidence ? He would be a bold man who, in 
the present state of the art, would venture to answer these queries in the 
affirmative. For our part, we are convinced that there is ample room 
for renewed observation and research ; but, unless a man can bring to 
bear upon the subject a mind unwarped by prejudice or preconceived 
ideas, his testimony will be of little avail. Take, by way of example of 
this, the second position. Who has not been summoned, again and 
again, to the bedside of a woman in labor, to find the head in the lower 
third of the pelvis, and in the position in question ? In such a case, the 
disciple of Naegele would probably record in his note-book, " A case of 
third position, in which rotation had occurred before my arrival." He 
is driven to this conclusion, if he adopts Naegele's theory, but yet, as 
regards the individual case, the evidence is Naegele's and not his. Or, 
again, if quite early in labor he finds the head undoubtedly in the second 
position, he classifies it as irregular, and assumes the presence of some 
of the '' various circumstances" in which only, says Naegele, this posi- 
tion can occur. To be candid, however, we must admit of the possibility 
of a mistake which is the converse of this, and which would be committed 
by him who should rank every case as second, without any reference to 
the stage at which the first examination is made. It must, we think, be 
manifest, that correct conclusions on this subject can only be based upon 
a large number of observations, in which the position of the head is 
ascertained, in every case, at the beginning of the labor, or before it 
experiences any pelvic resistance further than that which is due to 
gravity. 

Granting that the first position is by far the most frequent, occurring, 
as it does, in nearly TO per cent, of all cranial presentations ; and, 
granting further, as we do, that Naegele's discovery — that the third is, 
as a primary position, next to the first in point of frequency — is correct, 
we are persuaded that both second and fourth cases occur more fre- 
quently than is generally supposed, — certainly much more frequently 
than Naegele would have us believe. We are inclined to think that, by 
striking an average between the percentage yielded by the statistics of 
Dubois and Murphy respectively, we should come very near the truth. 

The proportion thus deduced stands nearly as follows : — 

First Position. Second Position. Third Position. Fourth^Position. 

67 10 20 3 



304 THE MECHANISM OF LABOR. 

The second cranial position is then, as we have shown, in most re- 
spects, both as regards pelvis and cranium, the converse of the first, and 
it is difficult to account for its comparative infrequency on any other 
ground than the presence of the rectum on the left side. It is somewhat 
strange that Naegele should reject this theory as improbable, as it is 
very obviously in favor of his argument that all cases, almost without 
exception, lie originally in the right oblique diameter; but perhaps we 
should, instead of being surprised at this, take it as evidence of his im- 
partiality. Whether the rectum may, or may not, have an influence in 
determining the original position, it is clear that it bears practically on 
the progress of labor, especially if distended. But, even should it be 
empty, it is conceivable that the thickness of the coats of the bowel may 
tend to make a tight fit tighter. 

The proportion of occipito-posterior positions which end with the face 
to the pubes is, for various reasons, very difficult to determine. It is 
not to be wondered at, perhaps, that great difference of opinion exists as 
to the proportion of cases which perform the usual rotation backwards ; 
but it is a little astonishing that the actual number of cases ending with 
the face forwards should be overlooked or misunderstood. Naegele did 
not believe in the fronto-anterior termination of such cases, except under 
peculiar circumstances, — such as a small head or a large pelvis, — but 
there are probably few accoucheurs of large experience, who take the 
trouble to observe what passes under their eyes, but have met with such 
cases, there being no peculiar circumstances whatever to account for 
them. Drs. Simpson and Barry came to the conclusion that, in the third 
position, spontaneous rotation occurred in 96 per cent. ; while, still more 
recently, Dr. West found that, in 481 cases observed by himself, 15 
which were in the third position were born, or were about to be born, 
with the forehead in advance ; but these included, it must be remembered, 
cases in which he rectified artificially the position of the head, on the 
assumption that, had he not interfered, they would certainly have termi- 
nated with the face to the pubes. In regard to rotation in the fourth 
position, the number of cases observed is so small that no reliable data 
are to be found ; but the impression generally prevails that spontaneous 
rotation, in such cases, is effected with greater difficulty, and the ten- 
dency to fronto-anterior termination is thus proportionally increased. 

Face Presentations. — The only other varieties of possible presentation 
of the cephalic extremity of the child which it is necessary here to con- 
sider are the various positions of the Face. These occur about once in 
230 cases. The causes which lead to this unusual occurrence are not 
well understood, but the initiatory movement which results in these pre- 
sentations can only be, as is obvious, a movement of extension which, at 
an early stage of labor, or prior to its occurrence, is substituted for the 
usual movement of flexion occurring during labor in the ordinary posi- 
tions of the cephalic extremity. In other words, and to take the most 
simple view of the matter, cranial are converted into facial positions by 
a simple movement of the head on its transverse axis. As, in this and 
other respects, there is a very close analogy between the mechanism of 
face and vertex presentations, we introduce the subject of the former at 



FACE PRESENTATION. 306 

this place from a conviction that it will be much more easily understood 
if studied along with the ordinary cranial positions. 

In pursuing the analogy which exists between the face and the vertex, 
we note, in the first place, that the obstetrical differs from the anatomical 
face in including the forehead. The long diameter of the face, there- 
fore, which extends from the centre of the forehead between the frontal 
protuberances to the tip of the chin, corresponds to the occipito-frontal 
diameter ; and, in like manner, the transverse diameter, from one malar 
bone to the other, corresponds to the bi-parietal measurement of the 
cranium. AVe observe, further, in looking closely at the facial oval, that 
the pointed chin represents the occiput, while the forehead is, in each 
position, the broad end of the long diameter. A premature and exag- 
gerated movement of extension of the head having thus, as we conjecture, 
converted a cranial into a facial position, we find that, in its descent and 
birth, it follows the same mechanical laws as those which govern the 
vertex. Movements are thus executed, which in every stage correspond 
to those already described, with this important distinction that the rela- 
tion which they bear to the trunk of the child is in some respects reversed. 
This Avill become apparent as we proceed. The face, like the head, and 
for similar reasons, descends into the pelvis with its long diameter in one 
or other of the oblique diameters of the brim. There are thus four 
positions in which we may find the face, according as the presentation 
may have been originally a cranial position of the corresponding number. 
It will be observed, however, as a most important distinction, that the 
numbers of the Mento- Anterior variety do not correspond to the occipito- 
anterior of the cranium. Each presentation as numbered is, we repeat, 
supposed to be produced from the corresponding cranial position, by a 
simple movement on its transverse axis. 

f T?- ^ -D w ( Face in Ri^ht Oblique Diameter ; 

rirst jrosition, ■{ ^ -• -, <? j 

Mento-Posterior, J^f^^^^^ff^™:^^- ^. , 

' Second Position, ^'^^ 'J' \'^} Oblique Diameter ; 

' I lorenead forwards. 



Mexto-Anteriok, 



( TTi- J r, ■^- ( Face m Risjbt Oblique Diameter ; 

Third Position, "i ^ i /i i j 

I ' ( loreliead backwards. 

1 XT' ^t D •^- (Face in Left Oblique Diameter; 

rourth Jrosition, ^^^.■^:^^^;^ 

I ' { lorenead backwards. 



The chin, in all these positions, being looked upon as the mechanical 
equivalent of the occiput, it follows that the Mento- Anterior varieties, 
in which the front of the child is turned forwards, are the natural termi- 
nations of all face cases. This, indeed, is the case in a much stricter 
sense than in presentations of the cranium, for reasons which will appear 
presently. We shall, therefore, in the first instance, consider these two 
positions ; and, as the fourth is the one which occurs most frequently, we 
shall commence with it. 

Fourth Position of the Face. — Although it is not the usual course in 
this position, we are entitled to assume it as possible that it may be pro- 
duced from the fourth cranial position, by a movement of the head on its 
transverse axis, w^hich brings the chin towards the right ileo-pectineal 
eminence, the head being extended so as to bend the occiput towards the 
nape of the neck. The long diameter, indicated by the direction of the 
nose, lies in the left oblique diameter, with the forehead towards the left 
20 



306 THE MECHANISM OF LABOR. 

sacro-iliac synchondrosis. The finger, on an examinatibn, first reaches 
the right malar bone, which is the part deepest in the pelvis, and the 
presentation itself is made out by feeling the nose, mouth, and other 
features, care being taken not to injure these delicate parts by rougli and 
careless manipulation. The long diameter descends obliquely, with the 
chin in advance, in proportion to the degree of resistance. The caput 
succedaneum will be found to involve the right malar bone, the right 
angle of the mouth, and the parts immediately adjoining. When the 
face reaches the floor of the pelvis, the chin is directed by the right 
ischial spine downwards and forwards, along the corresponding anterior 
ischial plane, while the forehead glides along the left sacro-sciatic liga- 
ments towards the hollow of the sacrum, precisely as in the second cranial 
position. Having reached the perineum, and probably still retaining a 
certain degree of pelvic obliquity, the chin now moves forward under the 
pubic arch. The perineum becomes distended, and the chin having 
moved sufficiently forwards to release the mental pole of the occipito- 
mental diameter, the emergence of the head takes place by a movement 
of flexion, the face being born forwards and upwards as the nose, fore- 
head, vertex, and occiput successively sweep over the perineum — all of 
which takes place with no greater difficulty than in an ordinary cranial 
position. The shoulders having descended in the right oblique diameter, 
the right shoulder is lowest and in front. This part, therefore, is, in its 
turn rotated from left to right, along the anterior plane of the left ischium, 
while the left shoulder retreats into the hollow of the sacrum; and in 
this position they pass, as has already been fully described, under cranial 
positions, a corresponding movement of restitution being at the same 
time performed by the head. The trunk and breech follow as under 
ordinary circumstances. 

Third Facial Position. — In this the mechanism is precisely similar to 
that which has just been detailed. The face, however, lies in the right 
oblique diameter, the forehead being to the right sacro-iliac synchondro- 
sis, and the chin in the direction of the left ilio-pectineal eminence. The 
left side of the face is lowest in the pelvis, and it is on this that the caput 
succedaneum forms. The chin descends, and rotation takes place as in 
the former case, only in the contrary direction, the details of the process 
being in every respect similar. 

First Facial Position. — In this, and in the remaining position, the 
prominence of the chin is turned backwards. Following the method 
which we have adopted with the view of maintaining as closely as pos- 
sible the analogy subsisting between facial and cranial cases, we observe 
that the Mento-Posterior positions correspond closely with the fourth and 
third cranial. As in the mento-anterior variety, we may accept the chin 
as representing the occiput. The First Facial Position is produced from 
the first of the head, by a movement of extension. Its long diameter 
corresponds, therefore, to the right oblique diameter of the pelvis, the 
chin being directed to the right sacro-iliac synchondrosis, and the centre 
of the forehead towards the left ilio-pectineal eminence. The chin thus 
occupies the situation where the occiput lies in a third cranial position. 
The part which is lowest in the pelvis, and which the finger feels from 
the vagina through the anterior wall of the uterus, is the right malar 



FIRST FACIAL POSITION. 



307 



bone. If the os is sufficiently dilated, we may feel through it the bridge 
of the nose. Carrying the finger, in reference to the position which the 
woman occupies, downwards and forwards, we may reach the forehead, 
the frontal suture indicating the path from the bridge of the nose to the 
anterior fontanelle ; while, by passing it in the opposite direction, up- 
wards and backwards, we may feel the ridge of the nose, and the mouth, 
where the alveolar ridge may be distinguished, and ultimately reach the 
chin. Should the resistance of the os, at this stage, be such as to cause 
the development of a caput succedaneum, it will be found to occupy the 
upper half of the right side of the face, and will generally, to some ex- 
tent, involve the eye. 

With regard to this position, the same observation may be made as in 
regard to the third of the cranium — that it may terminate in two ways : 
with the chin towards the hollow of the sacrum ; or, by a rotation for- 
wards, which, by bringing the chin upon the right anterior ischial plane, 
converts it into the fourth facial position, already fully described. Al- 
though Smellie, and many writers of merit since him, describe cases of 
facial presentation in which the chin passes into the hollow of the sacrum, 
and is bom over the perineum, it is only with difficulty that we can 
admit — for reasons which will be detailed afterwards — a bare possibility 



Fis. 117. 




Diagram showing Successive Stages of Eotation and Delivery in the Pirst Facial Position. 

of such a termination of labor by the natural efforts. The head, there- 
fore, adopts a course very similar to what obtains in third positions of 
the cranium. xVs in the one case the occiput, so in the other the chin 
descends, prior to rotation, somewhat in advance of the forehead. The 



308 THE MECHANISM OF LABOR. 

fronto-mental diameter being, however, more than an inch less than the 
occipito-frontal, the same degree of obliquity is not necessary as an essen- 
tial preliminary to rotation. And it is fortunate that it is so, for th'e 
head is already so strongly extended that a further extension seems all 
but impossible. In the course of the rotation, the chin comes in front of 
the right ischial spine, while the forehead moves upwards and backwards 
towards the left sacro-iliac synchondrosis, and the case is thus converted 
into what w^e have already described as the fourth position of the face. 
The rotation, therefore, which converts the first facial into the fourth is, 
if we read " chin" for " occiput," essentially the same as occurs when 
the third of the vertex rotates into the second. Less obliquity of the 
long diameter of the face being required, the rotation of the face takes 
place with greater ease, which is another reason why we should look upon 
this as the only natural termination of that position of the face which is 
the result primarily of a movement of extension of a head occupying the 
first position of the vertex. The accompanying diagram (Fig. 117) shows 
the various stages alluded to. 

Second Facial Position. — In this position the face is in the left 
oblique diameter, with the chin to the left sacro-iliac synchondrosis, and 
the forehead to the right ilio-pectineal eminence. The chin, therefore, 
lies in the direction Avhich the occiput occupies in the fourth cranial posi- 
tion, and the part which is lowest in the pelvis is the left malar bone. 
The normal and almost invariable termination of such a case is a rotation 
analogous to what is observed in the fourth position of the vertex. The 
chin in this way becomes applied to the left anterior ischial plane, along 
which it glides as in what we have described as the third facial position, 
so as to bring it under the arch of the pubis, where the labor is terminated 
in the usual way. 

The relative frequency in the occurrence of the various positions of 
the face might not unnaturally admit of considerable difference of opinion. 
For, if the ordinary positions of the cranium, which are so familiar to us, 
still admit of doubt in this respect, it is not to be wondered at, that doubt 
may still attach to this rare and, as some term it, faulty presentation. 
If we are correct in assuming, what is very generally admitted, that pre- 
sentations of the face are the result, in the corresponding positions of the 
vertex, of a simple movement of the head on its transverse axis, the num- 
bers which we have attached to the various facial positions have a special 
significance in indicating the original position of the head. But there 
the numerical correspondence ceases. For, the more closely we look at 
the relation which the one presentation bears to the other, the more 
obvious does it become that the chin is mechanically the analogue of the 
occiput, and that, therefore, the anterior surface of the foetus is turned 
forwards in all face cases which are to be regarded as normal. In 
cranial positions, on the contrary, the back is, as a rule, turned forwards. 
This, while it so far destroys the analogy between the two classes of 
cases, establishes between them more important practical points of re- 
semblance ; for, as our object is, in any assistance which we may consider 
ourselves justified in offering, to bring the occiput forward under the 
pubic arch in cranial positions, so in these also we use what means we 
can, with the view of aiding in a similar way the descent and precedence 



THE VARIOUS FACIAL POSITIONS. 309 

of the chin. The aphorism of Roederer might, in fact, if we substitute 
the word " mentum" for " occiput" be admitted as the leading principle 
upon which nature conducts all such labors. " Indifferens est quisnam 
sit capitis positio, modo pars conica atque arctissima, mentum nempe, 
descendat." 

In point of relative frequency, therefore, we must speak with some 
caution. No doubt can exist with reference to the fact that the third 
and fourth, or mento-anterior, positions are the natural terminations of 
all face cases. In what proportion of these, third and fourth positions 
of the cranium have become directly transformed, as we have conjeciured, 
into the corresponding facial positions, it is, and probably from the rarity 
of the cases always will be, impossible to determine. That such a trans- 
formation is possible, no one can deny ; that it is probable, we will ven- 
ture to assert. And, moreover, shoald it so occur, the change of a fronto- 
anterior position of the cranium into a mento-anterior of the face may be 
looked upon as a more fnvorable termination of a labor than the tedious 
process already described, which, in a certain proportion of such cases, 
brings the occiput over the fourchette before the face can pass from under 
the pubis. It is on this ground, indeed, that we have considered our- 
selves justified in taking note of these as distinct positions, and not merely 
as stages in the course of the other two. 

If we take into consideration, moreover, the enormous preponderance 
of cases in which the cranium or vertex presents with the forehead back- 
wards, we readily admit that it is much more than probable that the 
mento-posterior positions are, in the earlier stages of labor, the usual 
positions of the face. The fact, again, that, in cranial presentations, the 
first position occurs in nearly TO per cent, of the four varieties, suffices 
to account, on the principle of rotation, for the preponderance at the 
moment of delivery of fourth over third facial positions. But the fact 
recorded by iS^aegele, that the preponderance alluded to amounts only to 
twenty- two fourth, as against seventeen third, facial positions can only be 
accepted as confirmatory of his statements as to the frequency of the 
various vertex presentations, by supposing that the third position of the 
cranium is, as we have assumed, not unfrequently converted by simple 
extension into the corresponding position of the face. Otherwise, the 
disproportion would be much greater between the two mento-anterior 
terminations than he assumes. 

That mento-posterior positions may terminate as such in a large 
pelvis, or in cases of premature delivery, we may admit as possible. 
But, if we consider carefully w^hat this termination implies, in the case 
of an ordinary pelvis and a fully developed head, we find it impossible 
to conceive a degree of extension which would involve such compression 
and moulding of the head as would bring the occiput into relation with 
the dorsal vertebrae before the chin could reach the posterior commissure 
of the vagina. We believe, therefore, that the cases upon which the 
assertions of Smellie and others are founded must have been of the 
exceptional nature above referred to. And, if such cases do occur, the 
mechanism at the moment of birth of the head must be the arrest of the 
chin at the fourchette, and a movement of flexion which, while relieving 
the head from its constrained position, brings the mouth, nose, forehead, 



310 THE MECHANISM OF LABOR. 

and vertex successively in a backward direction from beneath the pubic 
arch. 

All presentations of the face were at one time supposed to be abnormal 
and dangerous. This belief gave rise to diiferent methods of operative 
interference, which were devised with the view of rectifying the presen- 
tation. Of these, the operation of turning found special favor in the 
eyes of the older accoucheurs, who did not scruple, as a matter of routine, 
to introduce the hand, and turn in all cases in Avhich the presentation was 
recognized at a period sufficiently early in the labor. Till the beginning 
of the present century, indeed, this was the mode of procedure which 
received the sanction of the most eminent authorities. The attention 
which about this time was directed to the subject of scientific obstetrics 
soon showed how erroneous w^as this view, and how greatly increased 
was the risk both to the mother and child by the operation of turning. 
But the idea of necessary interference of some kind had got too firm a 
hold of the professional mind to be at once dispelled, and we therefore 
find substitutes for the discarded operation sanctioned by the authority 
of some great names. We find, for example, that it was recommended 
by Dr. J. Clarke to allow the face to descend into the cavity of the pel- 
vis, and then, by steady pressure exercised upon the presenting malar 
bone during a pain, to push the face into the hollow^ of the sacrum, and 
allow the occiput to descend. That Dr. Clarke may have succeeded, as 
he says, in such cases, we must not doubt ; but we confess to great scep- 
ticism as to the feasibility of such a proceeding under ordinary circum- 
stances, and we have little doubt that, if we did succeed, the risk to the 
child would be rather increased than lessened. 

Until it had been demonstrated by Naegele, accoucheurs were quite 
ignorant of the rotation which occurs in the great majority of face 
cases, whereby, in mento-posterior cases, the chin spontaneously comes 
forward under the pubis. It was, therefore, a totally erroneous impres- 
sion of the nature of these labors which led Baudelocque to suggest, 
and so many of his followers to adopt, an operation which is scarcely 
less objectionable than turning. In recommending the operation referred 
to, he directs us to pass the finger through the os, and along the anterior 
wall of the uterus over the forehead, and then, rupturing the membranes, 
attempt to drag down the occiput. This he naturally conceived to be 
better than to leave the case to nature, believing as he did that all 
mento-posterior cases could only terminate as such. These and all other 
similar modes of procedure were at once thrown aside when the funda- 
mental errors from which they sprang w^ere removed by the industry and 
genius of Naegele. 

In face presentations, as they occur in actual practice, we believe the 
safest rule for our guidance is to avoid interference as far as possible. 
In occipito-posterior positions of the cranium, we have recommended in- 
terference in such cases only as threaten to terminate with the forehead 
in advance, and the same rule should guide us in our management of the 
face. When the chin is originally forwards, or has already rotated, no 
interference whatever is required. It is usually recommended, however, 
in the mento-posterior positions, to aid the rotation, either by hooking the 
finger into the mouth, and making cautious traction in the proper direc- 



ASSISTANCE ON FACE PRESENTATION. 311 

tion, or by some other mode of manual interference, with the view of 
bringing the chin towards the pubic arch, as the face is about to emerge 
from the pelvis. It is doubtful, however, whether such interference should 
be sanctioned as the proper routine procedure. So many delicate points 
have here to be attended to — the direction of the pressure, the time for 
operation, and the like — that we incline to the belief that nature should, 
in the great majority of instances, be trusted to. For, if the practitioner 
of average experience can have but a few cases to observe in the course 
of a lifetime, it is scarcely to be expected that he can attain such special 
skill as to act with unfailing precision. While, however, we can bear 
personal testimony to the possibility of operative rectification of these 
positions, we would, in ordinary cases of this nature, certainly prefer to 
watch carefully the process which nature is adopting, and act only in such 
instances as she may seem to be calling for assistance. 

It may be necessary, in facial as well as in cranial positions, to give 
assistance by manual or operative interference in cases in which delivery 
is delayed, although the parts are normally situated. Such aid as, under 
the circumstances, it may seem necessary to afi"ord, is to be employed in 
each case on the same principles. The only points which are here to be 
remembered as distinctive, arise from the facts — that in facial position, 
the vessels of the neck are, in consequence of the peculiar position, sub- 
jected to very unusual pressure, and that the adjacent maternal organs 
are also likely to be compressed by the manner in which the child's head 
is doubled back. Both of these conditions should lead us, therefore, to 
watch the progress of such a case somewhat more strictly than usual, in 
order, if possible, to detect the earliest indications of abnormal obstruc- 
tion to delivery, and so soon as this may arise, to relieve it without delay. 
The forceps, for example, may be employed in such cases, at a period 
somewhat earlier than is considered necessary in cranial positions, in pro- 
portion exactly to the imminence of the danger which we apprehend. 
Should it, however, occur that the head descends to the floor of the pelvis, 
and yet no effort is made in the way of rotation, it will be proper to aid 
the movement in question, having first carefully ascertained the position 
of the face, and calculated the direction in which our efforts should be 
applied. Persistent mento-posterior cases may possibly, as has already 
been said, terminate as such, if the child be premature or putrid, or the 
pelvis of unusual capacity; but if, owing to the disproportion of parts, 
or some other special cause, rotation should not be effected, the inevitable 
result is such obstruction as may be called insurmountable ; and in these 
instances the perforator and the crotchet may be required before the relief 
of the Avoman is effected. 

[If rotation cannot be effected by the measures recommended by the 
author, it is doubtful whether the obstruction should " be called insur- 
mountable," and the perforator resorted to without a trial of another 
measure. In November, 1873, 1 read a paper before the Obstetrical So- 
ciety of Philadelphia, on " The Use of the Hand to correct unfavorable 
Presentations and Positions of the Head during Labor." In this was 
related a case of face presentation, with the chin behind and to the right 
side, seen in consultation with Dr. Elliot Richardson. The face was 
almost at the inferior strait. All attempts to flex the head, to rotate the 



812 THE MECHANISM OF LABOR. 

chin in front, or to deliver by traction with the forceps failed. The woman 
was completely exhausted, and there seemed to be no alternative but to 
perform craniotomy. Before resorting to this, however, I passed my 
whole hand into the pelvis, and placed the thumb over the brow and the 
fingers over the superior maxillary bone, "and pushing forcibly upwards, 
the head was easily raised above the brim of the pelvis. It was then 
flexed without any difficulty, and a mento-posterior of the face was con- 
verted into an occipito-anterior of the vertex." Wallace's forceps were 
promptly applied, and a few minutes later we had the satisfaction of de- 
livering a living child. 

To successfully perform this manipulation the woman should be com- 
pletely under the influence of an anaesthetic. When the patient is tho- 
roughly relaxed by ether, "it is very surprising what can be done by 
forcibly pushing the head upwards. Not only does the child ascend, but 
if the lower segment of the uterus has been carried with the head into 
the cavity of the pelvis, it may be lifted with its contents above the pelvic 
brim, where the latter become movable and easily manipulated. Both in 
the pregnant and unimpregnated woman, the degree of stretching and 
movement of which the generative organs are capable when the patient 
is completely anaesthetized, appears very remarkable to one who has 
never employed this important agent in such cases." 

For further information in regard to this subject, the reader is referred 
to the paper alluded to, which was published in the American Journal 
of Obstetrics for May, 1875. It is not to be supposed that the measure 
here described will always prove successful, but the happy result of the 
case alluded to, warrants the hope that it will sometimes obviate the ne- 
cessity of resorting to the perforator, the most horrible of all obstetric 
instruments. — P.] 

Although but four positions are above described, it may be said of face, 
as of cranial positions, that there is no possible diameter of the brim 
which may not be occupied, in some case or other, by the long diameter 
of the face. And, in regard to the situation of the parts after they have 
descended in the cavity of the pelvis, it may be further noted, that cer- 
tain intermediate or modified presentations may possibly occur. Brow 
presentations, for example, are described by many writers, and, in so far 
as we may judge from comparative measurement and mechanism, are to 
be admitted as possible. They must, however, be always looked upon as 
of the most unfavorable nature, and one of the most formidable objections 
to Baudelocque's operation was the risk of thus converting an unfavor- 
able presentation into one which was, perhaps, even more so, should the 
attempt at artificial rectification be arrested midway in its course. A 
thorough knowledge of the mechanism of ordinary labor will be the best 
guide to the management of any such exceptional cases as may ofi"er 
themselves in the course of practice. 

We have attempted throughout, in the description which has been given 
of the four positions of the face, to indicate the strong analogy which 
exists between them and the ordinary positions of the cranium, which are 
so familiar to all. The prominence of the chin, therefore — be it once more 
remarked — is the analogue of the occiput. This is more clearly shown 



CRANIAL AND FACIAL POSITIONS CONTRASTED 



313 



in the following tabular statement, which is drawn up with the view, not 
only of showing the relation between facial and cranial positions, but also 
of enabling the student to store the facts in his memory, in such a form 
as may be most available for practical emergencies in any presentation 
of the cephalic extremity of the child : — 



Tabular Arrangement of the Presentations and Positions of the 
Cephalic Extremity of the Fcetus. 



occipito- 
Anterioe 
Positions. 



OCCIPITO- 

POSTERIOR 

P0SITI0>'S. 



Ckaxium or Vertex. 

I. Ill Right Oblique Dia- 
meter ; forehead to 
right sacro-iliac syn- 
chondrosis. 

I. In Left Obliqne Dia- 
meter ; forehead to left 
sacro-iliac synchon- 
drosis. 

f III. In Right Oblique Dia- 
I meter ; forehead to- 

I wards left ilio- pec- 

tineal eminence. 
Usually rotates into the 
2d. 

IV. In Left Oblique Dia- 
meter ; forehead to- 
wards right ileo-pecti- 
neal eminence. UsuaUi/ 
rotates into the 1st. 



Mento- 
posterior { 
Positions. 



Mento- 
anterior 
Positions. 



Face. 

I. In Right Oblique Dia- 
meter ; forehead to- 
wards left ilio-pectineal 
eminence. Rotates into 
the Ath. 

II. In Left Obliqne Dia- 
meter ; forehead to- 
wards right ilio-pecti- 
neal eminence. Rotates 
into the 3d. 



f III. In Right Obliqne Dia- 
meter; forehead to right 
sacro-iliac synchondro- 
sis. 

IV. In Left Oblique Dia- 
meter : forehead to left 
sacro-iliac synchondro- 
sis. 



In Cranial Positions, therefore, the third rotates into the second^ and 
the fourth into the first; while in Facial, the second rotates into the 
thirds and the first into the fourth. 



314 PELVIC PRESENTATIONS. 



CHAPTEE XIX. 

PELVIC PRESENTATIONS. 

Ihe Practice of the Past. — The Pelvis a Natural Presentation. — Dor so- Anterior 
and Dor so-Posterior Positions. — Breech Presentation ; Four Positions of. — 
First Position of the Breech : Rotation : Passage of the Buttocks : De- 
scent and Birth of the shoulders : Difficult Progress of the Head., and 
Mechanism of its Expulsion. — Second Position of the Breech. — Third 
Position of the Breech : Birth of the lower portion of the Trunk, and of 
the Shoulders: Flotation of the Face Backwards., and Mechanism of the Birth 
of the Head; Exceptional Terminations. — Fourth Position of the 
Breech : Special Risk of Pelvic Presentations. — Diagnosis and Peculiari- 
ties. — Knee and Footling Cases. — Management of Pelvic Presentations. — 
Nature of Assistance to he rendered. — Use of the Fillet, Vectis, and Blunt 
Hook. — Indiscriminate dragging on the Lower limbs to be avoided. — Treat- 
ment of case where Arms pass up alongside Head. — Management of the Funis. 
— Indications of impending death of the child. — Manipulation for effecting 
speedy Delivery of the Head. — Use of the Forceps. 

Although the writer of the obstetrical memoranda which were attri- 
buted to Hippocrates recognized the oval position of the child in the 
w^omb, and illustrated the impossibility of delivery in cross birth by the 
graphic simile of the olive in the neck of an oil jar, he, strangely enough, 
as has already been mentioned, omitted to perceive the full force of his 
illustration. For, as every oval has two ends, he ought to have con- 
cluded that the foetal oval could pass naturally with either of these in 
advance, as the olive might be extracted from the jar. Failing to ob- 
serve this, however, the ancients believed that presentations of the pelvic 
extremity were abnormal, and should in all cases be rectified by artificial 
aid. The result of such a mode of practice as this points to — which ob- 
tained throughout a period of several centuries — is looked at by the 
modern obstetrician with horror, on account of the fearful sacrifice of 
human life which such a procedure must have involved. There is 
nothing, indeed, in the history of MidAvifery comparable to this ; and the 
idea of turning by the head in all cases of pelvic presentation is one so 
repugnant to every principle of the science and art of obstetrics, that it 
is diSicult to perceive by what perversion of reason a blunder so fearful 
could have been perpetrated. Certain it is that, until the revival of 
anatomy by Vesalius, and even for some time after the art of printing had 
been discovered, the practice recommended in pelvic presentations was 
that which has just been indicated as dating from the time of the Ancients. 

It is to Ambroise Pard that we owe the correction of this monstrous 
error, and from his day these presentations have always been recognized 
as natural. Although much more dangerous to the child, they are 



POSITIONS OF THE BREECH. 315 

attended with no increase of risk to the mother. While, however, we 
prefer to consider presentations of the Pelvic Extremity as natural, it 
must be noted that many writers have thought it necessary to classify 
them as preternatural, an opinion which has given rise to much contro- 
versy, an analysis of which would serve no good or useful purpose. The 
pelvic end of the foetus is made up of certain anatomical elements which 
may present themselves in various combinations. The ordinary presen- 
tation is that in which the foetus preserves its usual intra-uterine attitude, 
with the limbs flexed, but with its axis inverted, so that the presenting 
part is the Breech. If, however, the inferior extremities become sepa- 
rated from the trunk, and thus occupy the inferior segment of the uterus, 
we may have other presentations which fall under the same category, 
such as presentations of the knees or of the feet, or of one knee or one 
foot. The classifications, therefore, of possible positions may be multi- 
plied by a little ingenuity to such an extent as to render the subject an 
extremely complicated one, and its study a wearisome task. Here, again, 
we owe much to the indefatigable industry of Naegele. For it Avas he 
who first showed that, although we may subdivide the positions ad in- 
finitum^ all pelvic presentations may, in so far as the mechanical pheno- 
mena of labor are concerned, be reduced to two classes according as the 
dorsal or abdominal surface of the child is turned forwards within the 
womb. We shall now proceed, therefore, to the description of the posi- 
tions of the breech, which will suffice for all possible presentations of the 
pelvic extremities. Certain peculiarities attach to cases of knee and 
footling birth, which, being of a practical nature, will receive a brief 
notice in the proper place. 

The structures which form the breech of the child are of a much softer 
and more yielding nature than the cranium, and are, therefore, within 
certain limits, more plastic and susceptible of adaptation to the parts 
through which they have to pass. Parturition is not the less on that 
account governed by fixed mechanical laws, according to which the parts 
enter, pass through, and emerge from the pelvic and parturient canal. 
To the consideration of these we now pass. In presentation of the 
breech we find no less marked a preference for the oblique diameters 
than in the case of the cranium, so that the child assumes a position with 
its back or belly forwards, and turned at the same time either to the 
right or to the left. The two main divisions of all such cases then are, 
according to Naegele and subsequent observers, Dorso- Anterior and 
Dorso-Posterior positions, the former being more frequent in the propor- 
tion of three to one. As each of these implies a possible position of the 
transverse or long diameter of the breech in either oblique diameter of 
the maternal pelvis, we may here, as in the cranial and facial cases, de- 
tail four Positions of the Breech as follows : — 



Dorso-Anteeior, 



r E'- * D V ( Breech m Left Oblique Diameter ; 

rirst Position, < i ^^ j. i j. ^ j 

I ' ( left trochanter forwards. 

I c J -D u- S Breech in Rio-ht Oblique Diameter ; 

becond Position. < ■ -, ^ ^ ^ , £ j 

t ' I right trochanter forwards. 

r T^7 • J D -v- \ Breech in Left Oblique Diameter; 

1 liird Fosition, { • i j. a i ^ i j 

DoESO-PosTEEiOR \ ^ ^"^«^^^ trochanter forwards. 

'It-, ^i n •^- ( Breech in Right Oblique Diameter : 

fourth Position, < i ^v .. v i. ^ j 

' I left trochanter forwards. 



316 PELVIC PRESENTATIONS. 

The breech is recognized, on a digital examination, by the ischial 
tuberosities, between which the genital organs, male or female, may be 
distinguished. As the parts are, however, frequently much distorted by 
what is equivalent to the caput succedaneum, it is not always so easy for 
the beginner to recognize the presentation as he may perhaps imagine. 
He may, in a hurried and imperfect examination, very readily mistake 
the tuber ischii, which his finger first touches, for the prominence of the 
shoulder, and the female genital organs for the fold of the axilla. It is 
well, therefore, that in every case he should make a leisurely examina- 
tion, in order to insure the accuracy of his diagnosis. The genitals, 
occupying a situation between two osseous prominences, one of which is 
usually considerably lower than the other, can scarcely be mistaken ; 
and, in the case of the male, the scrotum is generally tumefied. But, 
if any doubt should arise, this is set at rest if, in addition to the parts 
named, he recognizes the anus, the point of the coccyx, and the unequal 
osseous surface of the back of the sacrum. To this last point Cazeaux 
attaches considerable importance. At the commencement of labor, or 
even before it has come on, it may be possible to recognize a breech pre- 
sentation by palpation of the abdominal tumor, which, when the walls of 
the belly are thin and relaxed, enables us to recognize the general out- 
line of the child, with the rounded resistant cephalic extremity turned 
-towards the fundus and inclined a little to either side. The pulsations of 
the foetal heart are heard on a somewhat higher level, near the umbilicus. 
The absence in the vagina of the firm and smooth globular head, which 
generally occupies the lower segment of the uterus, would further cor- 
roborate such observations as the above. The presentation is, at this 
stage, higher than usual, and often beyond the reach of the finger; but, 
in knee and footling cases, the knee or heel may be felt lying against 
the most dependent part, and retreating before the pressure of the finger. 
In its general shape and external appearance, the uterus is not sensibly 
altered. 

Presentation of the pelvic extremity is by no means a rare occurrence, 
as it is met with once in about 45 mature births ; and, in premature de- 
livery, it is, for reasons formerly stated, much more frequent. Of 80 
pelvic presentations, observed by Dubois, 54 were ordinary breech posi- 
tions, and in 26 the feet descended in advance. Madame Lachapelle 
only saw the knees presenting once in 3445 instances of labor, and in 
the statistics of the Lying-in Hospitals of Wiirzburg and Prague, we 
find but one case in 9274. The breech is, however, not only the most 
frequent but the most favorable of the pelvic presentations. For, al- 
though at first sight it might appear that a footling or knee might, on 
the principle of the wedge, be a more favorable arrangement mechanically, 
an observation of the w^hole process at once shows that this is not the 
case. The broad breech, increased in bulk by the flexion of the thighs, 
performs a most important function in dilating the passages for the safe 
and rapid progress of the head, during the latter and more critical period 
of the labor ; and, as it is very evident that this will be more effectively 
done by the breech than by the footling presentation, the former is, from 
a mechanical point of view, undoubtedly the most favorable. 



FIRST POSITION OF THE BREECH. 



317 




First Position of the Breech. 



First Position of the Breech. — Of all the possible positions of the 
pelvic extremity this, which is shown in Fig. 118, is the most common. 
In it, the transverse or long dia- 
meter of the breech occupies the ^^^- l^^- 
left oblique diameter of the brim, 
so that, as the back of the foetus 
is turned forwards, it is the left 
ischial tuberosity which is lowest 
in the pelvis and upon which the 
finger impinges on examination. 
Backwards, and in the direction 
of the left sacro-iliac synchondro- 
sis, another similar projection is 
reached, and between the two, in 
a direction corresponding to the 
right oblique diameter, is a sulcus 
or depression, in which may be 
recognized, from before back- 
wards, the coccyx, the anus, and 
the external genital organs. In 
proportion to the resistance of- 
fered to the breech in its descent, 
there is an increase in its obliquity, 
w^hich brings the left buttock still 
more in advance, precisely as 

occurs in the descent of the occiput. When the breech reaches the floor 
of the pelvis, therefore, it is the left hip and posterior surface of the left 
thigh which comes upon the anterior ischial plane of the right side, while 
the right hip passes behind the left ischial spine and comes into contact 
with the sacro-sciatic ligaments of the same side. 

A rotation now takes place which is in every respect analogous to the 
cranial rotation already described, the left buttock gliding downwards, 
forwards, and to the left along the ischial plane and the obturator in- 
ternus, while the right buttock performs the corresponding movement 
from left to right towards the hollow of the sacrum. There is not in 
this case — as a comparison of the relative measurements will show — the 
same imperative necessity for rotation which obtains in the case of the 
head. But, in its birth, it follows the same mechanical law, with this 
difference only — that the rotation is, in the case of the breech, more 
rarely complete into the antero-posterior diameter than occurs when the 
head is in the presenting part. It might be supposed, following the 
analogy of the mechanism of the occipito-anterior positions of the vertex, 
that the left buttock passed upwards and forwards under the pubic arch, 
while the right swept over the perineum. Such, however, is not the 
usual mechanism of the process. The left buttock, indeed, moves for- 
wards to the arch, but at this point it is arrested and forms a centre, 
upon which the right buttock describes the arc of a circle, from before 
backwards on the distended perineum, so that, in the act of birth, it 
takes precedence of the left, which passes immediately afterwards (see 
Fig. 119). The long diameter still preserves to the last a certain amount 



318 



PELVIC PRESENTATIONS. 



of its obliquity, so that the right buttock is directed a little to the left of 
the middle line, and, so soon as it has passed, the feet and knees slip 
down, and with the movement of extension of the thighs the lower part 
of the trunk is born. The belly of the child thus lies towards the right 



Fi^. Ill 




Birth of the Breech. 



thigh of the mother. No marked movement of restitution occurs at this 
stage, because the shoulders are descending in the same oblique diameter 
as was occupied by the breech. If, however, the trunk of the child does 
not participate in the rotation of its pelvis, a certain degree of restitution 
may occur to relieve the twisting of the vertebral column. 

The thorax now occupies the pelvic cavity. The superior extremities, 
if normally situated, are in contact with the anterior and lateral parts of 
this region of the trunk. The long diameter of the shoulders, occupying 
like the breech the left oblique diameter of the pelvis, descends under 
the influence of successive pains. When the resistance of the pelvic 
floor is fully encountered, a movement is executed in every respect 
similar to that which is observed in the passage of the breech. The left 
shoulder comes forward towards the summit of the pubic arch, but is 
there arrested, so that the right sweeps over the perineum, and is born 
in advance of its fellow, as shown in Fig. 120. It happens, not unfre- 
quently, that one or both of the arms slip up during the descent of the 
trunk, and become applied to the sides of the child's head (see Fig. 
121), an accident which, in a pelvis below the average in its measure- 
ment, may give rise to considerable obstruction and delay. The original 
attitude of the head with reference to the trunk, in all breech cases, is 
with the chin flexed towards the sternum, which permits of the expulsive 
force being communicated to the trunk to the greatest mechanical advan- 
tage. Any movement of extension which may occur tends not only to 



BIRTH OF THE SHOULDERS. 319 

disturb the conditions upon \vhich a speedy labor depends, but may also, 
by allowing the hands to slip between the chin and the sternum, and 
thence to tlie side of the head, interpose a very serious barrier to the 
accomplishment of the labor, more especially if, as sometimes happens, 
one becomes locked behind the head, and between it and the pubic bones. 



]20. 




Birth of the Shoulders. 



As the shoulders are passing through the outlet of the pelvis, the head 
descends in the right oblique diameter. The point of essential distinction 
between pelvic and cephalic presentations becomes manifest at this stage. 
In the latter, the difficulty tenninates with the birth of the presenting 
part, but in the former the real difficulty commences at the corresponding 
stage. The passage of the breech is not attended with any special diffi- 
culty ; nor is the passage of the shoulders long delayed. But, instead 
of the difficulty ceasing with the birth of these parts, it becomes increased, 
and the really anxious and critical time of the labor now begins. For 
not only has the most unyielding part of the foetal oval still to pass, but 
it has to pass under circumstances which necessarily imperil the life of 
the child. Beyond a certain point, indeed, delay involves death to the 
child, so that the skilful management of this stage may be said to be one 
of the most important practical duties of the accoucheur. A cause which, 
at this moment, increases the risk, is the failure of expulsive force. This 
does not imply so much a failure of expulsive action as that, the uterus 
being now nearly empty, its propulsive energy is brought to bear upon 
the head at great mechanical disadvantage ; and it is difficult to see how, 
but for the contraction of the vagina, and of the muscles at the floor of 
the pelvis, nature could ever complete a case of pelvic presentation. In 
the position at present under consideration, the head descends with the 



320 PELVIC PRESENTATIONS. 

forehead turned towards the right sacro-iliac synchondrosis, and a little 
in advance. The occiput is turned towards the left ilio-pectineal emi- 

Fi<?. 121. 




Arm displaced upwards. 



nence, and after rotating towards the sub-pubic arch, is there arrested 
until the chin, nose, forehead, and vertex sweep successively forwards 

Fig. 122. 




Birth of the Head. 



and upwards over the distended perineum. Fig. 122 shows the head in 
this position immediately prior to the final act which terminates the 



second stage of labor. 



THIRD POSITIOX OF THE BREECH. 321 

Second Position of the Breech. — In this, the position is also clorso- 
anterior ; but, instead of occupying the left as in the position above 
described, the pelvis descends in the right oblique diameter. It is 
therefore the right ischial tuberosity which presents, and the right but- 
tock which descends in advance as far as the pubic arch, being directed 
towards it by the anterior inclined plane on the left side of the pelvis. 
The left hip sweeps over the perineum, and the shoulders descending in 
the right, and the head in the left oblique diameters, are successively 
expelled by a mechanism which is in all respects identical with that 
which obtains in the first position, only in the contrary direction as re- 
gards the various rotatory and other movements. At first it seems 
strange that this should be less frequent than the first position, and that 
nature should prefer the left oblique diameter, in breech cases, to the 
right ; and this too would almost seem to throw doubt upon the opinion 
we have expressed that she prefers the right oblique in cranial presenta- 
tions, in order to avoid the left which is encroached upon by the rectum. 
But, even here, if we watch the case to a termination, we find nature 
apparently guided in a majority of cases by the self-same law. For, as 
we have already seen, the really critical and important moment of a 
breech case is that during which the head passes through and out of the 
pelvis ; and it is on this account that in the more common first position 
the head is in the favorable diameter ; whereas, in the second, the head 
descends in the left, which is, as statistics would seem to show, more 
dangerous to the child, probably because detention of the head is more 
likely to occur. 

Third Position of the Breech. — Of 161 pelvic presentations occurring 
at Heidelberg, 121 had the back, and 40 the belly of the child turned 
forwards. This gives as nearly as possible a preponderance in favor of 
the two first positions, already set down at three to one. The third and 
fourth or Dorso-Posterior positions, then, are of comparatively rare oc- 
currence. 

In the Third Position, which occurs less frequently than any of the 
others, the breech lies in the left oblique diameter, which, as the back is 
turned towards the vertebral column of the mother, brinsis the rio;ht tuber 
ischii to the front, and deeper in the pelvic cavity. When it reaches 
the floor of the pelvis, the corresponding buttock glides along the right 
ischial plane, and attains the summit of the pubic arch, where it is 
arrested until the left ischium sweeps over the perineum, when the belly 
of the child is born towards the mother's left thigh. The shoulders 
descend in the same oblique diameter, and are expelled pretty much as 
in a dorso- anterior position. The head then enters the pelvis in the 
right oblique diameter, with the occiput towards the right sacro-iliac 
synchondrosis. In the great majority of cases, the termination of this 
position is by a rotation which brings the occiput from the sacro-iliac 
synchondrosis to the obturator foramen on the right side, and the fore- 
head from the obturator foramen to the sacro-iliac synchondrosis on the 
left side. In a word, the rotation is the same which converts a third 
into a second position of the cranium. This rotatory movement has, in 
some cases, been observed to take place at an earlier period in the 
labor. AVhen that occurs, the movement takes its direction from the 
21 



322 



PELVIC PRESENTATIONS, 



original rotation, which brings the right buttock in advance. It passes 
then, from right to left, into the conjugate, and a little beyond it, and 
ultimately continues the movement in the same spiral direction, until the 
belly of the child looks almost directly backwards. The trunk, in this 
case, participates in the rotation of the breech ; but if it does not so 
participate, the head itself, when subjected to the resistance of the pelvis, 
performs the extensive rotation which we have described. 

Cases are occasionally observed in which the rotation above described 
does not take place, and the head comes into the Avorld with the occiput 
turned backwards. The usual course in such a case is, that the head 
descends in the pelvis in a strong state of flexion, with the forehead and 
occiput turned to the anterior and posterior extremities, respectively, of 
the right oblique diameter. The usual movement of rotation brings the 
occiput along the right sacro-sciatic ligaments towards the hollow of the 
sacrum, and the forehead from left to right, under the sub-pubic arch. 
The original movement of flexion is then continued, so as to bring the 
face, forehead, and vertex, in succession, from behind the symphysis, 
while the occiput, around which, as a centre, this movement has been 
executed, is the last part to escape. It would also appear, from cases 
which are recorded upon good authority, that the head in this position 
may escape by a movement which is not one of flexion, but of extension. 
The occiput, in those rare instances, would seem to have preceded the 
forehead in its descent ; the chin rests upon the lower part of the sym- 
physis, and the occiput, vertex, forehead, and face successively emerge 
over the perineum, the depression between the chin and the trachea 
being the centre upon which the movement of extension occurs. 

Fourth Position of the Breech. — Of the two dorso-posterior positions 
of the breech, it is this which is more frequently met with. The long 

diameter of the hips occupies the 
right oblique diameter of the 
brim, so that, while the child 
sits, as it were, upon the brim of 
the pelvis, its anterior surface 
looks forward, and to the right. 
The left trochanter is towards 
the left ilio-pectineal eminence, 
and it is consequently the left 
tuber ischii which is forwards, 
and stands lowest in the pelvis. 
The breech and shoulders descend 
as in the third position, each per- 
forming; the same limited amount 
of rotation and external restitu- 
tion ; the head then arrives in 
the pelvis, in the left oblique 
diameter, the chin being in front 
of the right, and the occiput be- 
hind the left ischial spine. The 
forehead then rotates backwards, 

Fourth Position of the Breech. whilc the OCCiput traVCls aS in 



Fiff. 123. 




DIAGNOSIS OF PELVIC PRESENTATION. 328 

the corresponding positions of the vertex, from the left sacro-iliac syn- 
chondrosis, onwards along the left side of the pelvis, until it arrives at 
the sub-pubic angle, where it is arrested, and the face, forehead, and 
vertex sweep, as in the preceding presentation, forwards over the dis- 
tended perineum. The same exceptional cases may also occur as in the 
third position, and w^e should therefore be prepared for the possible oc- 
currence either of complete rotation before the head descends to the 
brim, or of one or other of the occipito-posterior positions which have 
been described. 

All presentations of the breech tend to terminate more irregularly 
than those of the head. The birth of the nates is perhaps attended with 
even less difficulty than that of the head in cranial presentations, but the 
real difficulty, in a breech case, is the speedy and safe passage of the 
head. And it is indeed remarkable, not only in regard to the first posi- 
tion, but also the fourth or more frequent of the two dorso-posterior posi- 
tions, that the head, in its descent by the normal path, avoids that 
oblique diameter which is contracted by the rectum. But whether this 
occurs or not, pelvic presentations are attended by special and greatly 
increased risk, which is greater, moreover, in regard to knee and footling 
cases, than when the breech presents. 

Something must here be said in reference to the diagnosis of knee and 
footling cases, but as regards the mechanism according to which labor 
under such circumstances is accomplished, no special description is neces- 
sary, as it differs in no material respect from what has been described in 
regard to the breech. The mechanism of all pelvic presentations is, in 
other words, essentially the same. Very little can be recognized with 
certainty, until the rupture of the membranes enables us to distinguish 
the various parts. The form of the bag of waters, upon which some 
have laid great Aveight in a diagnostic point of view, may certainly give 
rise to suspicion, although it can never by itself be of much importance. 
In all pelvic presentations, it is, as a rule, more pointed, and projects 
further into the vagina. In footling cases, the bag is long and sausage- 
shaped, and through it the foot or feet may be felt. When the mem- 
branes ultimately give way, the discharge of the liquor amnii does not 
take place with such a gush as in cranial positions, but on the other hand 
it is more continuous, and the drainage more complete. In cranial pre- 
sentations, the head, acting like a ball-valve, hinders the liquor amnii 
from escaping, except in small quantities, in the intervals between the 
pains ; but, when the irregular pelvic extremity presents, a more complete 
escape is permitted, which, by bringing the uterus to bear more power- 
fully and directly upon the surface of the child, no doubt increases the 
risk of its life. The foot is very liable to be mistaken by beginners for 
the hand, for although any one could distinguish between the two wdth 
the eyes shut, if he could bring the whole of his ten fingers to bear upon 
it, it is a very different matter when he attempts to recognize a part which 
can only be reached by a couple of fingers, and that possibly with diffi- 
culty. The length of the digits, and the mobility of the thumb as com- 
pared with the great toe, will prevent the possibility of doubt when we 
can recognize these points, but under circumstances of unusual difficulty, 
this may be impracticable. No single anatomical feature of the foot is, 



324 PELVIC PRESENTATIONS. 

in difficult cases, so characteristic as the prominence of the heel. The 
dorsal surface of the hand may be mistaken for the instep, and the fin- 
gers for the toes, but on the other side of the joint there is nothing in 
the hand which can be compared to the projection of the heel. If, there- 
fore, we can pass one finger over the dorsum of the foot, and another 
over the heel, which enables us to grasp the extremity of the limb like 
the head of a crutch, we may be perfectly confident that it is a foot and 
not a hand with which we have to deal. And we w^ould here observe, 
parenthetically, that this is one of many points, in regard to which the 
young practitioner should lose no opportunity of perfecting the tactus 
eruditus; for a mistake here, which is acted upon by operative or other 
interference, may bring discredit upon him, and, what is worse, may 
directly lead to the most disastrous results for his patient. The deter- 
mination of the position of the foetus from a single foot is a matter in 
reference to which some doubt may exist. The general direction of the 
toes will, however, indicate the abdominal surface of the child, and if 
both feet should present, this is much more certain. We may, however, 
have to wait for the descent of the breech before we can be certain to 
which of the four positions it is to be referred. A single foot should 
always, if possible, be identified as right or left, which is very easily 
done, if it be sufficiently within reach, by placing the palm of the hand 
to the sole of the foot in the same manner as is pursued in identifying a 
single hand, as will be more particularly described afterwards. 

The risk to the mother in presentations of the pelvic extremity is in 
no way increased ; for, admitting that the opinion generally expressed in 
regard to the tardy completion of the first stage is correct, we may as- 
sume that this is compensated for by the comparative ease with which 
the child makes its way through the passage. But the figures already 
quoted, which are confirmed by the experience of every one, show only 
too clearly that the risks to which the child is exposed are enormously 
increased. It is equally certain — as, indeed, is further indicated by the 
figures alluded to — that the risk is not the same in all cases of pelvic 
presentation alike, but is greatly increased in those cases in which the 
thighs are extended, and not flexed upon the trunk. The cause of this 
is to be found, as has already been observed, in the inefficient manner in 
which the canal is thus dilated for the passage of the head, which delays 
the completion of the labor at the critical moment, when, all being born 
but the head, it is arrested in the pelvis until the life of the infant is 
destroyed by suffocation. In an ordinary breech labor, the more com- 
plete dilatation of the parts reduces this risk to a considerable extent, 
but even under the most favorable circumstances the risk is, as compared 
with cranial births, enormously increased. And it is none the less cer- 
tain that, by prompt and skilful measures, the accoucheur will often have 
the gratification of saving lives which, if left to nature, would have in- 
evitably been sacrificed. A thorough knowledge of the mechanical phe- 
nomena above detailed, is the first essential qualification which may lead 
to skill and judicious management in the treatment of all cases of pelvic 
presentation. In order thoroughly to understand the subject, however, 
Ave must view it under various aspects. While we have no difficulty, for 
example, in recognizing that, in many instances, assistance is necessary. 



MANAGEMENT OF PELVIC PRESENTATIONS. 325 

we must not overlook the fact that injudicious interference is bad. We 
have to consider, therefore, not only what to do, but what not to do ; for, 
unfortunately, many errors in practice have been committed, and as some 
have had the sanction of great names, it is doubtful whether on this sub- 
ject sound practical views are entertained as invariably as they ought 
to be. 

Long after the preposterous idea of Hippocrates, alluded to in the 
beginning of this chapter, was exploded, views erroneous, but erroneous 
in a minor degree, obtained in reference to the treatment of presentations 
of the pelvic extremity of the child. We thus find Williams, Hunter, 
and Smellie bringing down the feet when the breech presents, as a matter 
of routine, but this, happily, has long fallen into disuse, except in difficult 
cases, as we shall see. 

It may be inferred from what has already been seen, that the duties 
and responsibilities of the accoucheur are, in the case of a pelvic presen- 
tation, greatly increased. In a cranial case, while all goes well, we look 
to the issue Avithout a shadow of apprehension ; and we absent ourselves, 
from time to time, without any consciousness of neglecting or evading a 
duty. But, when the pelvis presents, all is altered in this respect. The 
risk, be it again repeated, is a foetal, and not a maternal one ; but, as we 
cannot tell the moment at which our assistance may be required, we 
must be much more strict and continuous in our attendance ; and, so 
soon as the breech has descended in the pelvis, we must not leave the 
bedside of our patient until the delivery has been completed. This 
assiduity, on our part, does not involve, of necessity, any interference 
with the natural process, except at the last part of the second stage, 
when a little assistance in the passage of the head is almost always 
justifiable. 

Having fully satisfied ourselves of the exact position of the foetus, 
and thus recognized the manner in which the mechanism will probably 
be conducted, we simply wait and watch the issue. If nature takes the 
ordinary course, and the breech descends, whatever its original position 
may have been, in a satisfactory manner, we do not presume to interfere, 
by in any way hastening or aiding the labor. At this moment there is 
no special risk to the child, and, indeed, the slower the dilatation of the 
passage, the more effectual is that dilatation likely to be, and the safer 
and more rapid the subsequent birth of the head. So soon as the but- 
tocks and lower limbs are born, we know that the critical period ap- 
proaches ; and some anxiety is not unnaturally felt as to the subsequent 
progress of the case, as a condition now comes mto operation, constituting 
one of the special dangers of pelvic births. This is compression of the 
umbilical cord, which, as the thorax approaches the ostium vaginae, be- 
com^es jammed between the pelvic wall and the unyielding cranium, — a 
state of matters which, if complete and continuous, rapidly destroys the 
child, by interrupting the placental circulation. We should, at this stage, 
pull down a loop of the cord, thus obviating the probability of obstructed 
circulation by over-stretching, and at the same time guide it, if possible, 
in the direction of either sacro-iliac synchondrosis, — where the risk of 
pressure is least, — choosing, if choice there be in the matter, that sacro- 
iliac synchondrosis which corresponds to the side of the child's head. 



326 PELVIC PRESENTATIONS. 

Much useful information as to the prospects of the case is afforded by 
grasping the cord with the finger, so as to feel its pulsation. So long as 
this remains quite vigorous, the case is to be left entirely to nature ; but 
we must repeat the observation frequently, as the descent of the head 
may expose the cord quite suddenly to fatal pressure, — a fact which it is 
of the highest importance immediately to recognize. The persistence or 
failure of funic pulsation are, in fact, the chief indications as to the neces- 
sity for operative interference. 

Exceptional circumstances, no doubt, may arise to call for assistance 
at a stage even earlier than that which we are describing. Long deten- 
tion of the breech within the cavity, owing to disproportion of the foetal 
or maternal parts, or to inertia uteris may call for action at an unusual 
period, on the same general principles as will afterwards be detailed as 
applicable to the case of obstructed cranial labor. The operative pro- 
cedure proper to breech cases is, however, peculiar ; and, if we fail, by 
the use of ergot or otherwise, to arouse the dormant energy of the uterus, 
or should we recognize an obstruction which natural efforts cannot over- 
come, we must be prepared to act with a view to speedy delivery. The 
forceps, being specially constructed for application to the foetal head, is 
not generally available.^ The vectis, however, applied over the flexure 
of one thigh, while the hand of the operator is applied to the other, may 
possibly succeed ; and the blunt hook is an instrument which has been 
frequently recommended in the management of such cases. No one can 
doubt the mechanical power of these, and especially of the blunt hook ; 
but the danger of bruising, and even lacerating, the parts of the foetus is 
not inconsiderable, so that such means should, if possible, be avoided. 
When the child is dead, and much force has to be employed, the blunt 
hook, and even the crotchet, may be applied, — the use of which instru- 
ments will be more particularly detailed when we come to consider ob- 
stetric instruments and their use, under a special section. By the fingers 
alone, introduced over the groin upon the flexure of the thighs, the 
breech, in a very considerable proportion of ordinary cases, may be 
drawn down under the pubic arch, the operator remembering always, 
and imitating, as far as possible, the natural mechanism of the act. This 
is in all cases to be preferred as the safest ; but, should it fail, a second 
mode is still available, which is much safer than, and therefore to be 
preferred to, any variety of instrumental delivery. What is required 
for the operation is a handkerchief, or, what we have found even more 
satisfactory, a skein of cotton yarn. One end of this is to be passed 
between the thighs and the abdomen, in the flexure of the groins, to the 
corresponding point on the other side, where it is to be seized and pulled 
down. In this w^e have a powerful fillet so adjusted that we use a very 
considerable traction force without any risk of injury. It is sometimes 
possible — and the more so when the breech is high in the pelvis — to 
break up the presentation, by pulling down one leg. Should we employ 
this subsequently, for the purpose of traction, great care must be taken 

• It is proper to observe, however, tliat the forceps has frequently been used by 
Professor Hueter, of Marburg, and others. More recently, Professor Miles, of Cincin- 
nati, has invented a special forceps for breech cases, which he seems to have found 
in the highest degree satisfactory. 



OPERATIVE ASSISTANCE. 327 

not to use too much force, otherwise dislocation or fracture may be 
readily enough produced. 

The rule, however, is, as has been said, that we should interfere in no 
way whatever until the breech and lower part of the trunk have been 
born, when we direct our attention assiduously to the state of the cord. 
When the breech is born, and the legs lie between the thighs of the 
mother, and, in footling cases, even before the passage of the breech, an 
almost irrepressible desire may possess the accoucheur to grasp the limbs 
and to bring the labor to a rapid termination. Such, it is to be feared, 
is not unfrequently the practice of those who have not taken some pains 
to master the mechanism of pelvic births. In many cases, doubtless, the 
result may be what is de.-ired, but the hasty termination of the labor is 
thus purchased at an increased risk to the child. For the result of thus 
forcibly dragging down the body of the child is to separate, unless the 
uterine contractions are unusually strong and continuous, the chin from 
the sternum, against which it has been hitherto applied. The consequent 
extension of the head may thus result in a faulty position ; or, if the 
traction be continued, it may descend without undergoing the natural 
movement of rotation proper to the original position. The possible re- 
sult of this is only too obvious, and arises from the fact that under such 
circumstances the child's head is delayed in the pelvis longer than if we 
had left the case to nature, and thus, at the moment of all others at 
which speedy delivery is desired, the head is detained, and the child is 
suffocated, owing to the ignorance of the operator. But this is by no 
means the only manner in which his misplaced energy may defeat its own 
ends, for the separation of the chin from the sternum leaves a gap into 
which the hands are liable to slip from their position in front of the thorax, 
and from thence again to the sides of the head, which may thus, in a 
tight pelvis, be jammed at the brim. This, then, is an obvious error in 
practice wdiich the young practitioner should carefully avoid, and in re- 
gard to which midwives should be specially instructed and cautioned. 

The posture of the hands, and even of the arms, by the si'le of the 
head is an occurrence which, quite independently of unskilful interference, 
may spontaneously take place. Under all circumstances, it is an unfor- 
tunate complication, and requires, when recognized, immediate attention. 
So soon, therefore, as the lower half of the trunk has been born, and 
the cord has been looked to, we pass up the finger to ascertain the rela- 
tive position of the arms. Should these be in the posture of which we 
have just spoken as the natural one, no interference whatever is required, 
bat if they are applied to the sides of the head, it will be proper to bring 
them down singly. Selecting that one Avhich is most within reach, a 
finger is be hooked over the humerus, close to the elbow joint, when the 
arm is to be gently drawn forwards, so as to cause the forearm to sweep 
over the anterior surface of the child. If dragged down roughly, and 
Avithout any reference to direction, fracture of the humerus may occur, 
as has indeed often taken place in the hands of the ignorant or unskilful. 
The one arm being released, the head will probably descend a little fur- 
ther, and the other, coming thus more within reach, is to be treated in 
the same manner. We must be careful, durina; the passage of the 
shoulders, that the perineum is neither distended in such a manner, nor 



328 PELVIC PRESENTATIONS. 

in such a direction, as to endanger its integrity. The head, after the 
birth of the shoulders, now occupies the cavity of the pelvis, and the face, 
in almost all cases, will be found to have rotated into the hollow of the 
sacrum. 

This is the stage of greatest danger, and that at which the life of the 
child is most frequently lost. Consequently, it is the period which requires 
the most constant attention, and at which assistance has generally to be 
afforded. The powers of nature are, in a certain proportion of cases, 
sufficient to complete the delivery, so that even here there exists no 
necessity for operative interference as a point of routine duty. We must 
still, therefore, be guided by the circumstances of the case, and no single 
sign affords us more reliable information as to the urgency of the symp- 
toms, than the funic pulsation. The cord, however, now becomes exposed 
to more powerful pressure, and, at the same time, the function of the 
placenta is seriously interfered with, if not wholly arrested. The ab- 
sence, in breech cases, of the not inconsiderable quantity of liquor amnii 
which remains in ordinary presentations till the last, allows of the firm 
compression of the placenta between the head of the child and the ute- 
rine walls ; and even should this not take place, the great contraction of 
the uterine vessels permits of but a scanty supply of maternal blood for 
the oxygenation of that of the foetus. This, then, may truly be called 
a critical moment, in which, although placental respiration has all but 
ceased, aerial respiration is as yet impossible. A life trembles in the 
balance, and a few minutes at furthest will decide its fate. Impending 
death from asphyxia is indicated in such cases, not only by a failure in 
the circulation of the cord, but by failure of the heart's action, and by 
convulsive movements of the respiratory muscles and of the limbs. Such 
spasmodic attempts to fill the lungs with air are of the nature of reflex 
actions, excited probably by the contact of carbonated blood with the 
nervous centres. They indicate, therefore, impending suffocation, and 
call for immediate action. It is assumed, of course, that before matters 
have gone so far as this, we have in readiness such appliances as may be 
required, hot and cold water, and the forceps — everything in fact which 
may be requisite, whether for the delivery of the child, or its restoration 
should it be born, as frequently occurs, in a state of suspended animation. 

When the signs just mentioned indicate that the moment for operation 
has arrived, we must act without a moment's delay, a few seconds making 
all the difference between success and failure, life and death. The body 
and shoulders must not be grasped and pulled directly downwards, as is 
sometimes done. To do so would probably defeat our object, by pulling 
down the occiput towards the pubic arch, instead of favoring the natural 
movement of flexion ; and, besides, forcible traction of the neck is by no 
means free from the risk of causing instant death by injury to the spinal 
marrow. The following simple manoeuvre answers admirably in ordinary 
cases, and will rarely fail to release the head. The body of the child 
rolled in a napkin is laid along the right forearm, which is then carried 
upwards between the thighs of the mother, so as to bring the back of the 
child quite towards her abdomen. Very gentle traction is all that is 
necessary to combine with this movement, in order to permit the extrac- 
tion of the head, which is mainly efiected, indeed, by the flexion of the 



ARTIFICIAL DELIVERY OF THE HEAD 



329 



neck which is thus encouraged. Should this fail, the same movement 
may be combined -with extractive force, applied directly to the head by 
one or two fingers in the child's mouth, or what is better and safer, two 
fingers applied to the superior maxilla, one on either side of the nose. 
Some of the best authorities recommend a simple method by which all 
traction on the neck is avoided. In this, which is represented in Fig. 
124, two fingers of the left hand are introduced, as above described, 

Fi-. 124. 




Artificial Delivery of the Head iu Breech Cases. 



while the occiput is pushed upwards behind the symphysis by the corre- 
sponding fingers of the right hand:, the movement of flexion essential to 
delivery is in this way effected, while the face and forehead are drawn 
forwards along the distended perineum. By such a proceeding some 
have succeeded in establishing respiration, even before the head was 
born, and with this object in view. Dr. Bigelow has recommended the use 
of a flat flexible tube, which is to be passed within the vagina into the 
mouth of the child. All these manoeuvres must be varied, in cases of 
occipi to-posterior and other exceptional positions, in accordance with the 
natural mechanism of each case. 

If, however, the resistance is unusually great, we must, in preference 
to dragging upon the neck, apply the forceps without delay to the sides 
of the child's head, and thus complete the delivery. If the child does 
not at once breathe, the usual means described under suspended anima- 
tion must be adopted and persevered in, so long as the slightest chance 
remains of preserving the life of the infant. Any exceptional circum- 
stances which may constitute impediments to delivery, must be managed 
on general principles ; and, in extreme cases, it may even be necessary 
to perforate behind the ear, and allow the contents of the cranium to 
escape. Should the child be dead, many of the precautions above de- 
tailed will of course be unnecessary. 



330 TRANSVERSE PRESENTATIONS 



CHAPTEE XX. 

TRANSVERSE PRESENTATIONS: COMPLICATED 
PRESENTATIONS. 

Transverse Presentations: — The Arm or Shoulder the Presenting Part. — 
Causes of. — Signs of, before and during Labor. — Premature RujAure of the 
Membranes to be avoided. — Dor so- Anterior and Dorso-Posterior Positions. — 
Determination of Exact Position by Observation of the Hand. — Probable Course 
of an Unaided Case. — Occurrence of Spontaneous Evolution. — Spontaneous 
Expulsion. — Methods of Operative Assistance: Period of Labor to be selected: 
Cephalic Version: Podalic Version: Method of Combined External and In- 
ternal ManipulatioTi : Special Difficulties. — Procedure Modified if Child 
Dead. — Compound or Complicated Presentations. — Hand and Head. — 
Hand and Foot, Sfc. — General Management of these. 

In the Cross Birth of Hippocrates, the axis or long diameter of the 
foetal oval is thrown across the womb — the most unfavorable position 
which could by any possibility be selected. There is scarcely a point on 
the surface of the trunk of the body in regard to which we may say that 
its presentation at the os uteri is impossible, and it is not to be wondered 
at, therefore, that some writers have described an infinite variety of 
Transverse Presentations. Experience has, however, shown that, what- 
ever may be the case with a premature or putrid foetus, the presentation 
of a mature and living child, which has unfortunately assumed this posi- 
tion, is generally a presentation of the arm and shoulder from the first. 
And, moreover, in the exceptional instances in which some portion of the 
dorsal, thoracic, or abdominal surface presents, it has been found that these 
are usually converted into shoulder or arm presentations by the descent 
sooner or later of these parts. For those reasons, and for this additional 
one — that the mechanism in all transverse cases is essentially the same — 
cases of cross birth maybe considered solely as arm or shoulder presenta- 
tions : and, when these have been fully described, it will be found that 
little remains to be specified in regard to the other possible presentations 
of the trunk. According to the elaborate statistics of Dr. Churchill, the 
superior extremities enter the pelvis in advance of the rest of the foetus 
once in about 230 cases. 

The Causes of transverse presentation are, although obscure, probably 
somewhat less so than in the case of the breech. Any fault or deformity 
in the structure of the pelvic brim, which may act by preventing the 
descent of the head into the cavity, may turn aside, towards the iliac 
fossa, that extremity of the foetal ovoid, when the shoulder may slip down 
and take its place. In like manner, an unusual quantity of liquor amnii 
may, by destroying the ovoid form of the uterus, indirectly encourage 



CAUSES OF TRANSVERSE PRESENTATION. 331 

the displacement in question; while uterine obliquity, and premature 
expulsion of the foetus are also undoubted causes. The unfortunate ten- 
dency to a recurrence of this presentation in women who have already 
had a child or children presenting by the superior extremity, would 
almost seem to indicate that some anatomical peculiarity of the parts may 
be the cause ; and it was this which led Wigand to suppose that the form 
of the uterine cavity was the determining cause, and that, in those cases 
in which cross birth occurred, the transverse diameter of the uterus was 
in the first instance augmented, the long diameter of the cavity being 
thus relatively diminished. 

There are signs Avhich, when distinct, may lead us, before the occur- 
rence of labor, to suspect the existence of a transverse presentation ; but, 
until the presenting part comes within reach of the finger, it is generally 
a matter of considerable difficulty to form a confident opinion. The 
increased attention which has of late — more particularly in the German 
Schools — been given to the study of abdominal palpation promises, how- 
ever, to add. precision to our diagnosis in this and other similar conditions 
where the pregnancy is sufficiently advanced and the abdominal walls are 
not unusually thick. In most cases, the belly of the woman is peculiar 
in shape, and elongated in a transverse direction ; and, if the abdominal 
walls are lax and thin, we may recognize a tumor in each iliac fossa, one 
of which is more resistant and spheroidal, and the continuity between 
which may be established on palpation. It is sometimes possible to dis- 
tinguish the hand, elbow, or shoulder, through the anterior wall of the 
uterus, from the vagina; but, generally speaking, when we discover the 
presenting part in this situation, the most we can say is that we feel a 
part which resembles the shoulder. Such an observation, however, asso- 
ciated with careful abdominal palpation, may point to a quite definite 
conclusion. The stethoscope gives us no reliable information ; but there 
are cases, as Cazeaux observes, in which our diagnosis receives confirma- 
tion from this source. "If," he says, " the vaginal examination has 
resulted in the recognition of a portion of the foetus which is of small 
bulk, and if we perceive the pulsations of the heart in the hypogastric 
region, we may almost certainly conclude that it is the superior extremity. 
If we heard the heart at the level of the umbilicus, it would in all pro- 
bability be a leg." It happens, even more frequently in transverse than 
in breech presentations, that it is impossible to reach any portion of the 
foetus with the finger alone in the earlier stages of labor ; but, in some 
of these, the nature of the case Avill be recognized by introducing a por- 
tion of the hand. A marked efiect of the height at which the foetus 
stands, is slow, and comparatively painless, dilatation of the os ; and, 
when the bag of water forms, it is, as in the case of the breech, very dif- 
ferent in shape from that which precedes the head. In transverse pre- 
sentations, the shoulder is the part which usually oifers itself at the os 
uteri ; but, as a considerable period often elapses before it comes within 
easy reach of the finger, it is often not recognized until labor has made 
some progress — a fact which bears in an unfortunate manner, as we shall 
see, upon the ultimate issue of the case. 

It is, indeed, of the very highest importance that, if we have to deal 
with a cross birth, we should recognize the presentation as soon as it is 



332 TRANSVERSE PRESENTATIONS. 

possible to do so ; and when we have discovered a shoulder, an arm, or 
a hand, we should not rest satisfied until we have exactly, and to our 
perfect satisfaction, ascertained the position of the child. The promi- 
nence of the shoulder may be confounded with that of the tuber ischii, 
but may readily be distinguished by the absence of a similar tuber, at a 
little distance, with the genital organs between ; and, should this negative 
evidence not be deemed sufficient, the finger passed towards the axilla, 
so as to feel the ribs, will remove, if they can be reached, such doubts as 
may remain. Care must be taken, in such manipulation as may be 
necessary, to avoid rupturing the membranes ; for, so long as the child 
is not forced down upon the, brim, and these remain intact, they are pro- 
bably fulfilling their normal function of dilating the os, a process which 
should not, if possible, be interfered with. But, should the membranes 
be ruptured, or the shoulder be forced downwards, after rupture, into the 
cavity of the pelvis, and if we are still in doubt, it will' be proper cau- 
tiously to pull down the arm and hand, which enables us not only to make 
sure of the presentation, but to recognize the particular position by a 
simple method to be hereafter described. There is no evidence that this 
procedure has any bad effect upon the progress of the case or otherwise, 
and the unanimous opinion of the most experienced accoucheurs is that, if 
carefully done, it is quite free from risk. But, even if a certain amount 
of risk necessarily attached to the operation, we would be perfectly jus- 
tified in incurring it, in preference to attempting the management of the 
case without certain knowledge as to the position of the child. Some 
difficulty might occur in distinguishing the parts, if not within easy reach. 
The manner in which the hand is recognized under such circumstances 
has already been referred to in the preceding chapter ; but if, as will 
generally be observed, the arm hangs down into the vagina, there can be 
no difficulty whatever in distinguishing it from the lower extremity even 
by the inexperienced. The anatomical characters of the knee and elbow 
Avould enable us to distinguish also between these parts in the unlikely 
event of such a difficulty arising. 

We have alluded to the caution to be exercised in manipulating, so as 
to avoid premature rupture of the membranes. There is, however, one 
advantage in this mode of procedure to which we have not alluded : this 
is the possibility of rectification of a transverse presentation. This has 
been observed by competent persons too often as a spontaneous occur- 
rence, to admit of doubt as to its being an exceptionally fortunate issue 
of the difficulties of such a case ; but, it must be manifest that no such 
alteration in the axis of the child can occur when the waters have 
drained away, and it is grasped firmly by the uterus and forced in 
part into the cavity of the true pelvis. Ancl not only this, but we know 
by experience that the change may, in favorable circumstances, be eff'ected 
by a method to be afterwards described as that of Dr. Braxton Hicks, or, 
if the OS is inaccessible by the finger, even more simply by external 
manipulation alone, after the method of Wigand. 

If we except certain complicated and unusual cases, we may refer 
all transverse presentations to two varieties — ^Dorso-Anterior and Dorso- 
Posterior — of which the former is more frequent in the proportion of two 
to one. In dor so-anterior positions (Fig. 125) the back of the child is, 



DORSO-ANTERIOR POSITIONS. 



333 



as in the corresponding positions of the pelvic extremity, turned forwards. 
But, as the head may lie either to the right or to the left, there are thus 
two varieties of this position, in one of which, the head being to the left 
side of the mother, the right shoulder presents ; while in the other, the 
head is to the right, and consequently the left shoulder is the presenting 
part. These varieties bear no relation whatever to the pelvic diameters. 
Nor, if we consider that they are preternatural as regards the uterine 
diameters, can we even admit that they bear any such possible or prac- 
tical relation to these, as would warrant us in placing them in the same 



Fig. 125. 



Fig. 126. 




Transverse Presentation.— Dorso-Auterior. 



Transverse Presentation. — Dorso-Posterior. 



category as the presentation of the ends of the foetal ovoid -which we 
have hitherto been considering. There is here no question — primarily 
at least — of oblique, transverse, or conjugate diameter, so that a separate 
description of the two varieties of dorso-anterior position is quite un- 
necessary. The same remark applies to the dorso-poHterior position 
(Fig. 126), which in like manner offers itself for consideration under 
two varieties. In one, the head is to the right, and the right shoulder 
presents ; in the other, the head is to the left, and the left shoulder pre- 
sents. As regards the two principal positions mentioned, as well as their 
varieties, it is unnecessary to enter upon any elaborate description, as 
the management is in all cases essentially the same. The nature of the 
operative procedure which, in the great majority of instances, is neces- 
sary in the treatment of transverse presentations, renders it important 
that w'e should begin by ascertaining the exact position of the foetus. 
Indeed, should we make a mistake in this particular, we know of a cer- 
tainty that our error adds to the maternal risk, which is already con- 
siderable. Of great importance, therefore, is it that we possess the 
power of discrimination between the four positions which have been 
alluded to. 

The points which we wish to ascertain are — to which surface of the 
womb, anterior or posterior, is the back of the child turned ? and, to 
which side, right or left, is the head directed ? To ascertain this by 
passing the hand within and around the womb would of itself be a serious 



334 TRANSVERSE PRESENTATIONS. 

operation ; but we have fortunately a safe and certain means by which, 
under all ordinary conditions, we may at once determine the exact rela- 
tion which the child bears to the uterine walls, and so modify our opera- 
tive manipulations accordingly. The information in question is to be de- 
rived from a careful examination of. the arm which presents. Prior, 
therefore, to any operation which we may find it necessary to perform, 
with a view to the rectification of this faulty presentation, we must pull 
down the arm, and carefully observe it, unless, indeed, our examination 
of the presenting shoulder, and the parts beyond, should have sufficed 
clearly to establish the position of the child. The point to be first ascer- 
tained is, as to the presenting arm, whether it be right or left. This is 
determined, in the simplest possible way, by the accoucheur placing the 
palm of his hand against the palm of the child's hand — his finger tips 
pointing upwards towards its forearm — when, if the thumbs correspond^ 
so do the hcmds. For example, if he employs, as most people do, the 
right hand, and finds the thumb of the child correspond to his little 
finger, he knows that it is the left hand, while if he finds them thumb to 
thumb, it is the right. This is a certain guide, and one in reference to 
which there is no possibility of fallacy ; but the information which is 
thus aiforded is but limited, and only indicates that we have to deal with 
one of two possible positions. A more careful examination of the hand 
gives us complete and certain information, so that we know exactly where 
to find the anterior and posterior surfaces, and the head and feet of the 
child. The following rule is all that is necessary to remember : The 
hand of the child being supine, the Palm corresponds to the abdominal 
surface and the Thumb poiyits to the Head. Here, however, there is a 
possible source of error, which, if not avoided, will inevitably lead to 
wrong conclusions. For, a moment's consideration will suffice to show 
that, if we omit to make sure that the hand is supine, we run the risk of 
its being pronated, which, by turning the palm towards the back, and the 
thumb towards the feet, may lead us to form an opinion which is, in 
every respect, wrong. Before making the observation, therefore, be sure 
that the hand is supinated — when error becomes impossible. 

When the body of the child presents transversely at the brim of the 
pelvis, the labor almost invariably requires at the hands of the accoucheur 
the assistance of art. Indeed, it may be said that, if the pelvis be normal, 
and the foetus living, mature, and of average size, it is impossible for the 
woman to be relieved by the unaided efforts of nature. The progress 
and termination of such a case would probably be as follows : After a 
tedious first stage, in which the dilatation of the os is unsatisfactorily 
effected, the membranes rupture, and the arm descends into the pelvis, 
either primarily, or, when the shoulder originally presents, after the labor 
has made some further advance. When this occurs, the pains become 
much more severe and strong, and with each succeeding effort the shoulder 
is forced down, and wedged into the cavity of the pelvis. The head be- 
ing situated, however, to one side, and the breech to the other, progress 
beyond a certain point is manifestly impossible, so that when the utmost 
degree of moulding is attained of which those parts are susceptible, and 
the base of the wedge has entered the pelvis as far as the mechanical 
conditions will permit, no amount of uterine or other propulsive effort can 



SPONTANEOUS EXPULSION. 335 

produce the slightest effect. Left to nature, and attended with powerful 
uterine action, such a case must ere long involve the life of the child, not 
less by the great and continuous pressure on the neck and other vital 
parts, than by the implication, from the same cause, of the placental cir- 
culation. The actual degree of the pressure is further shown by the 
tumefaction of the limb which hangs down into the vagina, or protrudes 
partially from the ostium vagina. The sufferings of the mother are in 
no way alleviated by the death of the child, but, on the contrary, every 
minute of such fruitless effort renders her position more and more preca- 
rious. The continued pressure on the soft parts of the paturient canal 
may destroy in this way the vitality of the portions most exposed to its 
influence, when sloughing, more or less extensive, will occur, from the 
effects of which, coupled with the prostration and exhaustion which gradu- 
ally wear out her powers of constitutional endurance, her sufferings are 
terminated by death. Or, at any stage of the labor, rupture of the uterus 
may occur, and a similar result will, almost inevitably, ensue. 

Under certain circumstances, however, nature may relieve herself by 
a spontaneous process of delivery. The process of Spontaneous Evolu- 
tion is associated with the name of Denman, who discovered that, in some 
fortunate instances, nature afforded relief by what might otherwise be 
described as a process of spontaneous version. He found that, in those 
cases, the shoulder, or point of the wedge, did not maintain its position 
in the pelvis, but moved upwards, during the continuance of the pains, 
towards the brim of the pelvis, on that side which the head originally 
occupied, the head itself moving in a corresponding direction in the iliac 
fossa. This ultimately made way for the nates, which descended towards 
the floor of the pelvis, when labor terminated as if the case had been 
from the first a presentation of the breech. This observation of Den- 
man's was hotly controverted by some of the most eminent obstetricians 
of the day, with the ultimate result, however, of establishing the cor- 
rectness of his views. The controversy, moreover, by directing general 
attention to the phenomena of spontaneous delivery, resulted in a thorough 
elucidation of the whole subject, from which it transpired that there was 
another process, and one of more frequent occurrence, according to which 
a similar result ensues. The credit of first describing this is generally 
attributed to Dr. Douglas, of Dublin, who to distinguish it from the pro- 
cess of Denman, called it Spontaneous Expulsion. The mechanism of 
this differs essentially from the former, as the shoulder, instead of as- 
cending, continues to descend, until it becomes fixed against the sub-pubic 
arch, when it is arrested and forms a centre, upon which the whole body 
of the child revolves. It is obvious that such a mechanism as this can 
only be possible under exceptional conditions, such as a putrid or imma- 
ture foetus, or a pelvis of unusual size. For in this case the breech must 
pass the pelvic brim which is already partly occupied with the base of 
the skull, an occurrence which is manifestly impossible if the relative 
proportion of the parts, maternal and foetal, are in accordance with the 
normal standard. The mode in which the successive stages of the ex- 
pulsion actually occur is shown in the accompan3^ing figures, in which is 
depicted the manner in which, while the child revolves, the thorax, but- 
tocks, and remaining shoulder succeed each other in their passage over 



336 



TRANSVERSE PRESENTATIONS, 



the distended perineum. All being thus born but the head, the delivery 
of that part may either be effected by the natural efforts, or with the 



Fig. 127. 




Spontaneous Expulsion First Stage. 



assistance of the accoucheur in a manner already fully described in the 
last chapter. The long continued ineffectual efforts of the uterus, result- 



Fiff. 128. 




Second Stage. 



ing m complete atony of its muscular structure, may at this stage cause 
the death of the woman by hemorrhage so profuse that all our efforts are 



OPERATIVE INTERFERENCE, 



337 



powerless to arrest it, an unhappy result which is more likely to occur in 
those cases in which operative assistance has been too long delayed. 



Fig. 129. 




Third Stage. 



Thei'e are, perhaps, no cases occurring in the practice of midwifery 
which call for more tact, judgment, and operative skill, than those which 
are now under consideration. The object of all operative interference is 
the rectification of a preternatural presentation, so as to place the axis of 
the child in correspondence with the axis of the uterus, and thus permit 
of delivery in consonance with the mechanical laws which govern the 
normal process. Deliberately to leave the case to nature, on the chance 
of the occurrence of spontaneous evolution or expulsion, would be irra- 
tional in the extreme. For, although the risk of operative procedure 
must not be under-estimated, we may be quite certain that the danger 
which will accrue from delay is vastly greater, inasmuch as the child's 
life is sacrificed, and that of the mother is placed in imminent peril. It 
is scarcely possible in these days that, in this or any other civilized 
country, a woman would be suffered to die undelivered, for sooner or 
later assistance w^ould be sure to reach her. Such assistance, however, 
there is too good reason to believe, may be afforded at a period when the 
vital powers have already begun to flag, when the arm and shoulder are 
already wedged down in the pelvis, and Avhen the life of the child has 
long been destroyed. All these circumstances increase very greatly the 
gravity of the case, and may often lead us to despair as to its ultimate 
issue ; but, whatever the difficulties may be, the educated accoucheur 
must be prepared to cope with them, and to act in every case, even the 
most desperate, in such a manner as may at least give the mother what 
chance human skill can afford her. No one point, therefore, is of such 
22 



338 TRANSVERSE PRESENTATIONS. 

importance as this — that we should recognize the position at the earliest 
possible moment. If we have the good fortune to do so early in the 
labor, we may look upon the case with calm self-reliance, knowing that 
the issue lies in a great measure in our hands. No pressure having at 
this time compromised the life of the infant, w^e hear its heart beating 
vigorously, and we may possibly feel it move ; while the maternal parts 
have as yet been subjected to no mechanical violence. No details are 
requisite to prove that, in the two classes of cases referred to, the pros- 
pect of success is very different, and we therefore repeat that nothing, in 
point of importance, is to be compared with an early recognition of the 
case. This enables us, m.oreover, to select the time at which we may 
act with the greatest probability of success. 

The choice thus afforded us must be taken advantage of with discrimi- 
nation, and in full view of the facts which have been detailed. The 
responsibility which devolves upon the accoucheur in such a case, renders 
it essential that his services should be at command on any emergency, 
such as the arrival, somewhat earlier than he might perhaps have been 
prepared to expect, of the moment favorable for operation. For, as will 
presently be made apparent, this period may be of short duration, and if 
it be not taken advantage of, the case may pass very rapidly into another 
category in which the risk to mother and child is greatly increased. It 
is of the first importance, as has already been mentioned, that the integ- 
rity of the membranes should be preserved as long as is possible. Any 
clumsiness or violence of manipulation during the course of an ordinary 
vaginal examination, may thus, by causing the escape of the waters, not 
only permit of the descent of the abnormal presentation, but may, by 
complete evacuation of the liquor amnii — upon the same principle as in 
pelvic presentations — bring the uterine walls into immediate contact with 
the surface of the child. This is all the more likely to occur if we 
examine during a pain, so that we should carefully avoid examination at 
this mom.ent, or at least conduct it with special caution. The patient is 
to be confined strictly to the horizontal posture, but so long as the child 
is alive, the os but partially dilated, and the presenting part still high, it 
is better to wait than to attempt a forcible dilatation of the os, which 
would most likely involve a rupture of the membranes. This is the 
period, hoAvever, at which an attempt at rectification may be made with 
considerable prospect of success, if we combine the use of the finger 
internally with the external manipulation of Wigand, according to the 
method first suggested by Dr. M. B. Wright of Cincinnati. After having 
ascertained the exact position of the child, or at least the side to which 
the head is turned, this may be effected by pressing the shoulder upwards 
from the vagina, while the head is pressed down towards the brim of the 
pelvis, and if necessary retained there, by the other hand which is ap- 
plied to the surface of the abdomen. The process effected by this 
manoeuvre is what is termed Cephalic Version. The same result has 
been successfully attained by Hamilton, Gooch, and others, by manipu- 
lation which is purely internal, and by Wigand and Martin, by a method 
in which the manipulation is exclusively external, but it is to Wright, 
and more particularly to Braxton Hicks, that w^e owe a full exposition of 



TURNixa. 339 

the combined method.^ This subject will be more fully noticed under 
the head of Turning in a special chapter, so that we shall only mention 
here such points as are incidental to the peculiar case which we are now 
considering. 

The treatment most generally adopted in transverse presentations is 
the operation known as Turning or Podalic Version, to be afterwards 
more particularly described. (See Chap. XXXI.) Should this opera- 
tion be determined upon from the first, the integrity of the membranes is 
of even greater importance than before ; and the state of matters which 
is most favorable to its successful performance is to be found when the 
OS is in such a condition, as regards dilatation or dilatability, as to per- 
mit the passage of the hand, should that be necessary, while, as yet, the 
liquor amnii has not escaped. Waiting patiently till full dilatation has 
been attained, or till rupture of the membranes takes place, increases in 
no way, as we have seen, the risks of the case. But, so soon as either 
event occurs, we at once proceed to the operation by introducing the 
hand, seizing a foot, and bringing it towards the os uteri, whence the 
shoulders will recede, — under such circumstances at least, — without dif- 
ficulty. The mode previously detailed of ascertaining the position of 
the child by observation of its hand must here be practised if necessary, 
as the result of an error in this respect, or a bap-hazard introduction of 
the hand within the womb, will greatly increase the risk to the mother 
which attends the operation, even when most skilfully performed. The 
position of the child being ascertained, the palm of the child's hand will 
indicate the abdominal surface, to which the hand of the operator should 
always be directed, while by pushing the hand in the contrary direction 
to that in which the thumb points, the feet will most easily be attained, 
and at a minimum of risk. The method of combined version is equally 
applicable for podalic as for cephalic version. And it requires no argu- 
ment to show that, if it be practicable thus to effect the object in view, an 
operation which consists in the introduction of one, or at most two fingers 
into the uterine cavity, must involve less risk than necessarily attends 
the ordinary procedure of turning by the feet. That it is practicable, 
we have had several opportunities of demonstrating, and it is without 
an}" hesitation, therefore, that we recommend that this method should in 
the first instance be tried in every case, and the more severe operation 
only in those instances in which the former fails. As in its application 
to cephalic version, it is better to attempt rectification so soon as the os 
has sufficiently dilated to admit the finger, and to permit an accurate 
diagnosis. With the escape of the waters, the mobility of the foetus is, 
for obvious reasons, diminished. 

The following, from Dr. Hicks' published cases, is a striking instance 
of how, even under most unfavorable circumstances, combined version 
may be practised with perfect success: — 

"Mrs. M , admitted into Mary Ward in April, 1861. The ant ero- posterior 

diameter of pelvic brim measured only two inches and one-eiglitli, which had caused 
her labor to be accomplished with the greatest difficulty ; embryotomy being employed 
on the last occasion, although brought on at the seyenth month. Labor was induced 



^ See Dr. Braxton Hicks' Memoir "On Combined External and Internal Version.' 
-London, 1864. 



340 TRANSVERSE PRESENTATIONS. 

on 13tli April last, in the seventh month of this her fonrth pregnancy, hy puncturing 
the memhranes. Pains came on in ahout sixty hours, after which they continued to 
increase for twenty-four hours, at intervals of five minutes. The os uteri was then 
about the size of half-a-crown, still unyielding, scarcely admitting two fingers. The 
liquor amnii still existed in small quantities, draining slowly away. The shoulder 
presented, the head being to the right side, the breech to the left, but both approach- 
ing the fundus, the child being somewhat doubled on itself. As it was of much im- 
portance to rectify the presentation before the os dilated, so that the presenting part 
might not be driven lower down ; and as the footling presentation seemed, with so narrow 
a brim, and a small soft head, to give the best chance for the life of the foetus, I de- 
cided on attempting podalic version. The patient was put under the influence of 
chloroform. The left hand was introduced into the vagina, with two fingers through 
the OS, and the presenting part pushed in the direction of the head, while the right 
hand pressed down the breech from without. The foetus did not glide round in the 
uterus very easily, for it was tightly clamped by it, and every movement within or 
without produced uterine action, consequently it required a little patience ; but by 
varying the position and direction of the outside pressure, the foot was at last drawn 
into the os by two fingers. The chloroform was discontinued, and after about half-an- 
hour, slight expulsive pains appearing, gentle traction was made upon the child. It 
was not long before the os dilated, and the child was brought down during the pains. 
Some detention of the head took place at the biim, in consequence of the very narrow 
antero-posterior diameter, and the child's life was lost. The mother did very well." 

The really difficult cases, and those in regard to which apprehension 
will naturally arise, are those in which we have to act after the shoulder 
has descended in the pelvis, and when the body of the child is tightly 
embraced by the womb. No attempt should be made under any circum- 
stances to replace the hand and arm, should these have prolapsed ; and 
it will generally be proper, before proceeding to operate, to allay the 
excited irritability of the uterus, which shows a spasmodic tendency to 
contract under the slightest stimulus. Of various means at our command, 
that which is most suitable for this purpose is anaesthesia, and if the 
patient be well brought under its influence, it is wonderful to w^hat extent 
we succeed, in some instances, in relaxing the parts, so as to admit of the 
easy passage of the hand. In every case, however, such an operation is at- 
tended, as compared with one performed at an earlier stage of the labor, with 
greatly increased risk, the danger being in direct proportion to the amount 
of resistance encountered in an attempt to pass the hand. The condition of 
the bladder and rectum should, as a matter of course, be ascertained, and, 
if necessary, those viscera emptied before any attempt is made at rectifi- 
cation. A peculiar and special resistance may proceed from the state of 
the OS, which, if rigid, may constitute a barrier to the passage of the hand. 
In this case, if the waters have escaped, and the probability of its dilatation 
within a given time is thus a matter of great uncertainty, we must endeavor 
to dilate the os, either by the finger in a manner which will be afterwards 
described, or by means of some such mechanical appliance as Barnes' 
bags, and then proceed in the usual way. We may be summoned to 
cases in which, although the wedging of the shoulder is complete, clear 
evidence is afforded us of the death of the child. The proof of death 
may consist either in the signs of actual putrefaction, when the skin will 
peel off" the presenting part, in the observation of a flaccid and pulseless 
funis — w^hich is not unfrequently prolapsed in these cases — and in the 
absence of foetal pulsation and movement ; of which signs the first two 
may be regarded as certain, while the last is to be accepted with caution. 
Our procedure here is to be modified by the fact that we have noAV no 
longer the interest of the child, but that of the mother alone to look to, 



COMPOUND PRESENTATIONS. 341 

SO that our object simply is to deliver her in such a manner as may sub- 
ject her to the smallest possible risk. If, therefore, in this case, there is 
any special difficulty in turning, we should at once reduce the bulk of 
the child by evisceration, or bisect its long axis by decapitation, and then 
proceed to extract it in the manner which may seem safest and best. 

In a very few cases, in which the special circamstances favorable to 
such an occurrence are present, it may be obvious that the case is about 
to terminate spontaneously, according to the methods of Douglas or 
Denman. This will be recognized in each case by careful examination, 
— more especially during the pains, — which will enable us to make out 
that the process of revolution is being gradually effected. Delay is, 
under such circumstances, quite proper, more especially when the child 
is dead. With reference to spontaneous expulsion. Dr. Douglas says, 
" If the arm of the foetus should be almost entirely protruded, with the 
shoulder pressing on the perineum ; if a considerable portion of its 
thorax be in the hollow of the sacrum, with the axilla low in the pelvis ; 
if, "with this disposition, the uterine efforts be still powerful, and if the 
thorax be forced sensibly lower during the pressure of each saccessive 
pain, the evolution may, with great confidence, be expected." 

Compound or Complex Presentations. — In addition to the various 
presentations already described, there are many others, of rare, though 
possible, occurrence, in which certain parts, anatomically distant from 
each other, come together towards the os uteri. Most of these presenta- 
tions are varieties of transverse presentation ; but in some, again, the 
coincidence of the long axis of the child with that of the uterus is main- 
tained. We shall only mention here one or two of the many possible 
compound presentations. When the Hand and Head present together, 
the mechanism of natural deliv^ery is, of course, complicated to the extent 
of the diameter of the arm. In a pelvis of large, or even of ordinary, 
dimensions, there is nothing to prevent a satisfactory termination of the 
labor ; but, if the pelvic diameters should chance to be ever so little oat 
of proportion, the presence of the arm may make all the difference in the 
world, and suffice to jam a head which would probably have passed, 
under the ordinary conditions, with very little more difficulty than usual. 
Nay, even when a hand presents on either side of the head, there is 
nothing absolutely to prevent the birth of the child, which has, in fact, 
been observed to pass, under such circumstances, without any marked 
difficulty whatever ; so that, in both of these instances, Ave have to deal 
with conditions very different to those w^hich obtain in cross-births. But 
the chance of delay and protracted suffering is sufficient warrant for us, 
in such cases, to attempt a rectification of these presentations, if only 
this can be effected without incurring; the risk of makino; matters worse. 
What we wish to do is to push the arm upwards, so as to allow the head 
to descend, and alone to occupy the cavity of the pelvis. In making 
such an attempt, however, we must be particularly careful not to displace 
the head ; for, if the result of our interference were to be that the head 
was moved from the brim to the iliac fossa, and the shoulder thus 
permitted to descend, we would, in plain language, find that we had 
converted a comparatively favorable presentation into one of the most 
unfavorable which it is possible to conceive. For this reason, it is 



342 TRANSVERSE PRESENTATIONS. 

generally better to avoid all such attempts until the head has entered, or is 
becoming engaged in the pelvic brim. If we then use ordinary caution 
in our manipulation, we may attempt, without hesitation, to eifect our 
object by pressing the prolapsed limb steadily upwards ; and, along with 
this, we should try to retain the head against the brim, in such a manner 
as to prevent the slipping down of the arm, until the uterine efforts have 
caused the head to descend so far that this is no longer possible. This 
latter indication has been successfully fulfilled by combining external 
with internal manipulation, and that in a manner which would encourage 
us to repeat the manoeuvre on any occasion which might occur. 

The Feet and Hands, or one of each, may present, and thus constitute 
what may be termed an unusual variety of transverse presentation. It 
is a common occurrence, in this variety, to find prolapse of the funis as 
a further complication, and one unfortunately which will add in no small 
degree to our perplexity. As Ave could scarcely expect in such a case 
to replace both limbs, and as prolapse of the cord of itself involves very 
setious danger to the life of the foetus, the very obvious and proper pro- 
cedure is to draw down the inferior extremity, and thus complete podalic 
version. For, if we leave it to nature to select by which of the poles of 
its long diameter the child will descend, it is more than probable that the 
shoulder will slip down, and the difficulties of the case will then be very 
greatly aggravated. Or, as is still more likely, the upper and lower 
limbs will together become wedged into the pelvis, and the progress of 
the labor be as effectually barred as in the ordinary transverse position. 
If the mobility of the foetus within the womb is as yet not seriously in- 
terfered with, no great difficulty will be incurred in the operation, and as 
the child revolves, its arm will leave the vagina and follow the head in 
its movement towards the fundus. But, if the child is so firmly grasped 
by the womb as to render the operation unusually difficult, the woman 
must be put under the influence of chloroform, and a fillet attached by a 
running noose above the ankle (see Chap, xxxi.) when steady traction 
upon this, combined with pushing up the arm, with the further aid of ex- 
ternal manipulation afforded by an assistant, will usually effect the ver- 
sion. Should the cord have formed one of the elements of the original 
presentation, great attention must be paid to it, in order, if possible, that 
it should retreat into the uterine cavity along with the superior extremity ; 
failing which, it should be guided into that part of the pelvis where it is 
least likely to be exposed to injurious pressure. The case, otherwise, is 
to be managed as an ordinary footling presentation, and delivery slowly 
or rapidly effected according to the urgency of the symptoms and the 
other attendant circumstances. 

Presentations more complicated still may be, although rarely, en- 
countered. We may have, for example, the Hand and Foot presenting 
along with the Head, or we may have, as in the case which is represented 
in the accompanying engraving, a presentation of the Forehead, Hand, 
Foot, and Cord. All such cases are to be managed on similar principles 
by the performance of podalic version. In the case here represented, 
the whole of the presenting parts were tightly jammed in the pelvis, the 
child firmly embraced by the uterus, and the cord flaccid and pulseless, 
before it was brought under' our observation. The woman had previously 



COMPOUND PRESENTATIONS. 



313 



borne several children at the full terra. Although greatly exhausted by 
a fruitless labor of many hours' duration, her pulse was of tolerable 
strength ; and it was resolved, after the administration of some stimulants, 
at once to proceed to the operation. Version was, however, in this 
instance, effected with extreme difficulty, in the manner above alluded to, 
by the hand and the fillet. When the child was born, it was found to 
assume, as if from imperfect cadaveric rigidity, the attitude which it had 
occupied within the womb. This was so characteristic that a cast was 
taken, of which the drawing is a tolerably correct representation. Other 
complex presentations, in addition to those enumerated, may, as we have 
said, be met with, but the above will suffice to indicate the general prin- 
ciples upon which their treatment is to be based.- 

Fi-. 130. 




Case of Complicated Presentatiou. 



xlll cases of transverse and complicated labor are attended Avith greatly 
increased risk as regards the child : and, even under the most favorable 
circumstances, with a considerable addition to the dangers which women 
undergo in childbed. In the former class, it has been found that, even 
including those cases in which the most skilful assistance has been 
afforded, more than a half of the children perish, while, as regards the 
mother, the deaths are about one in nine. The fatality in both depends, 
in a very great measure, as all experience has shown, upon the period or 
stasie of the labor at which assistance is first afforded. 



344 FUNIS PRESENTATION 



CHAPTEE XXI. 

FUNIS PEESENTATION. 

'■''Presentation''' and '■'■Prolapse'' of the Cord. — Relation of the Funis to other Pre- 
sentations. — Causes of. — Symptoms of at Various Stages of Labor. — Great 
Danger to Child. — Treatment : at first Expectant: avoid rupture of the Mem- 
branes: Reposition hy the Fingers; hy Mechanical Appliances : Various Re- 
positoria described : Postural Method : Use of the Forceps: Turning. 

Some Avriters have, without anj obvious advantage, drawn a distinction 
betw^een " presentation" and prolapse of the Umbilical Cord. By the 
former term is implied those cases only in which a portion of the cord is 
situated in the lowest part of the amnionic cavity, so that it may be felt 
from the vagina ; either through the inferior portion of the uterine wall, 
or through the membranes, when the finger can be passed by the os. 
Prolapse, again, is restricted to cases in which, after the rupture of the 
membranes, a loop of the cord passes into the vagina, or even hangs from 
the vulva — in both cases preceding that portion of the child's body which 
presents at the os uteri. Such a distinction as this is, in so far as classi- 
fication is concerned, obviously useless, seeing the Prolapse is merely a 
more advanced stage, and an almost inevitable sequence, of the Presen- 
tation. 

At the beginning of labor, the funis may present alone at the os, and 
may be felt to occupy the bag of waters before the child has descended ; 
or, what is more usual, it descends along with the cranium, nates, shoulder, 
or any other part of the foetus, becoming prolapsed only when the mem- 
branes give way. Presentation of the cord is an occurrence which, al- 
though not very frequent, is so hazardous, as regards the life of the child, 
that we cannot pass it by without careful attention. Considerable dis- 
crepancy exists as to the frequency of its occurrence, and it has been 
variously stated by competent and experienced observers at from 1 in 37 
to 1 in 382. There can be little doubt that it often occurs without its 
being recognized — in those cases chiefly in which the loop is small, and 
the prolapse consequently trifling. This may, in some measure, seem to 
account for the discrepancy alluded to ; but we may confidently accept 
of the statistics carefully compiled by Dr. Churchill — which, on a total 
of 90,983, give one case of funis presentation in 282 — as indicating, 
approximately at least, the state of the case. It is in cranial presenta- 
tions that prolapse of the cord most frequently occurs — a fact which 
depends wholly upon the great preponderance of these as compared with 
the other presentations. Considered, however, relatively to transverse, 
breech, and the rarer presentations, we find that it is most frequent with 
the shoulder, then with the breech, and, in point of fact, is more likely 



CAUSES. 345 

to occur in any other presentation (relatively to its actual frequency) 
than in cranial cases, where the ball-valve formed by the head is, as we 
shall show, less likely than any other part to admit of the descent of the 
coil. Scanzoni brings out the following as the result of his experience : — 

Funis presenting once in 304 Cranial Cases. 
" " " 32 Face Cases. 

" " *' 21 Presentations of Pelvic Extremity. 

" " " 12 Transverse Presentations. 

The Causes of funis presentation vary according to the presentation 
of the child, and are also influenced by other circumstances. Among the 
predisposing causes, an unusual quantity of liquor amnii is a condition 
which, by separating the uterine walls from the surface of the foetus, 
must certainly encourage the displacement in question ; and it is men- 
tioned by Scanzoni that, in more than a third of the cases observed by 
him, an unusual quantity of liquor amnii existed. Probably, the larger 
the quantity the more likely would be the descent of the cord ; so that 
in cases of Dropsy of the Amnion we might anticipate the probability of 
such a displacement. In the case of a cord of unusual length, the con- 
ditions are also such as singularly to favor its gravitation downwards, 
either prior to the rupture of the membranes, or during the escape of the 
waters, when the loop suddenly slips down along with the gush of fluid. 
In cases where the placenta is inserted near the os, and the cord lies, 
consequently, in its immediate vicinity, the danger of prolapse must 
manifestly be increased, and will, on the contrary, be reduced, the further 
the site of the placenta is from the lower segment of the womb. It is 
doubtful whether a pelvis of unusually large size favors, as some have 
supposed, the descent of the cord ; in fact, we are inclined to believe 
that so far from this being the case, the unusual depth in the pelvis of 
the presenting part, in these cases, is more likely to prevent the accident, 
by a firmer contact than usual with the inferior part of the uterine cavity. 
But it is otherwise with a narrow pelvis, and more especially in such in- 
stances as show marked contraction at the brim. In these, the descent 
of the presenting part, and the occupanc}^ by it of the inferior part of 
the womb, are mechanically hindered, to such an extent that the cord is 
either forced down by the uterine contractions into the bag of waters, or, 
upon the escape of these, is carried past the arrested head by the impulse 
of the momentary torrent. Cases of this kind have been recorded by Mr. 
Roberton of Manchester, who has paid particular attention to the subject. 

There is, probably, nothing which acts more decidedly in producing 
this unfortunate situation of the cord than the nature of the presentation. 
The more thoroughly the lower region of the womb is occupied by the 
corresponding portion of the child, the less likely is prolapse to occur: 
and we find, therefore, that the less efl"ectively this condition is main- 
tained, there is, in direct proportion, increased danger to the cord. In 
the case of the cranial positions, a very superficial observation of the 
facts of the case will suffice to show how admirably adapted these are 
to the mechanical prevention of the displacement in question. It is true, 
indeed, that it is not the head which, in the first stage of labor, presses 
during a pain upon the os, and it might be assumed, as by no means 



346 FUNIS PRESENTATION. 

improbable, that the cord should slip down into the interval between the 
membranes and the head. But a more close attention to the mechanism 
of a labor-pain — which has been fully described in a previous chapter- 
shows that nature, apparently, provides against such a movement on the 
part of the cord, by commencing the contraction in the cervix, from 
whence it passes upwards, and thus, by a sort of inverted peristaltic 
action, maintains the relative position of the parts, which is only likely 
to be disturbed under such peculiar circumstances as have been above 
detailed. So soon as rupture of the membranes permits of the immediate 
application of the head to the circumference of the os, the same action, 
beginning in the sphincter fibres of the cervix, and exercised equally 
upon the spheroidal cranium, still more effectually prevents displacement. 

It is widely different in the other presentations of the child, which we 
may here consider together. In the case of the face, the conditions 
approach more closely to those of cranial presentations than to any other ; 
and we thus find, as we might have anticipated, in the table quoted above 
from Scanzoni, that these are, next to the cranial positions, the most 
favorable. As regards presentation of the nates, we have here also a 
rounded mass, occupying the lower segment of the uterus, in a manner 
which in most cases is sufficient to maintain the position of the cord. 
That its descent occurs in a much larger relative proportion of cases than 
in cranial presentations, is to be accounted for by various circumstances. 
We cannot fail to observe, in the first place, that there is not the same 
regularity in the circumference of the presenting breech as in the case of 
the head. There are thus, necessarily, various points at which the con- 
tact between the uterus and the presenting mass is comparatively insuf- 
ficient, so that the cord may easily glide down at those points where the 
resistance is least. We can easily conceive it possible that, in this man- 
ner, a loop of the cord may slip down over the genitals in the interval 
between the nates and pass into the vagina. Should the presentation be 
one of the knees or feet, the conditions favorable to a descent of the cord 
are even more exaggerated. It is in transverse presentations, however, 
that the cord most frequently descends along with, or in advance of, the 
presenting part. There is, in this case, but little to prevent the displace- 
ment in question ; and neither the shoulder nor the arm can be looked 
upon as, in any sense, the mechanical equivalent of the cranium, and 
what makes matters worse, in the case of cross birth, is the proximity, in 
every case, of the umbilicus to the os uteri, which must still further mul- 
tiply the conditions favorable to displacement. But, of all possible cases, 
those in which prolapse or presentation of the funis is most likely to occur 
are what have been described in the preceding chapter as complicated 
presentations — such as hand and head ; hand and foot ; head, hand, and 
foot ; and the like — in which the conditions favoring prolapse reach their 
maximum. 

Sudden rupture of the membranes, with the accompanying gush of 
waters, has been placed by some in the first rank as a determining cause 
of prolapse of the funis. This is claiming for the phenomenon in ques- 
tion too important a position. No one can deny that " prolapse" of the 
cord usually takes place at this moment, but the determining cause of the 
displacement has, probably in almost all these cases, been previously in 



SYMPTOMS. 347 

operation, and has already induced a descent of the cord as far as, prior 
to the moment of rupture, is possible. It may, no doubt, happen that, 
under special circumstances, such as abundance of the liquor amnii, a 
loop of the cord may be carried down past the presenting part along with 
the fluid; but the usual occurrence, we apprehend, is that the prolapse 
at the moment of rupture is merely a more advanced and complete stage 
of previous displacement. 

The Si/mjitoms by which this accident is to be recognized vary accord- 
ing as the membranes are intact or ruptured. In the former case, the 
diagnosis is attended with considerable difficulty, inasmuch as we can 
only be guided by the sense of touch through the membranes or the thin 
uterine walls. It is quite possible, at this stage, to mistake the inequali- 
ties which are presented by the fingers and toes for the irregularities due 
to the twisting of the cord ; and, in such cases, the only sign upon which 
we can confidently rely is the observation of the umbilical pulse. This 
is, however, not always easily made out, unless we are able to compress 
the cord between the finger and the presenting part of the child. And, 
even when we do feel pulsation, we must be cautious not to mistake the 
pulsation due to enlarged maternal vessels, which are to be distinguished 
by the synchronism of the latter with the radial pulse. It is, then, une- 
quivocal foetal pulsations only wdiich are to be accepted under those cir- 
cumstances as satisfactory evidence of the displacement which we are 
now considering. Whatever doubt may exist as to the nature of the case 
is at once dispelled by rupture of the membranes, when the loop of the 
core escapes into the vagina, or may even pass so far down as to come 
into sight at the orifice of the vagina. But, should the coil be small, or 
any other circumstance prevent its prolapse, no difficult}^ w^ill be met 
with in perfecting the diagnosis, as the cord may now be felt distinctly, 
rolling beneath the finger, and its pulsation may be ascertained by com- 
pressing it directly between the fingers ; while the fingers and toes, 
should these parts have given rise to doubt, may, by a similar method of 
examination, be readily distinguished. There is one possible source of 
error, against which the inexperienced observer must here be on his 
guard. It occasionally happens that, in extensive rupture of the uterus, 
a coil of the small intestine passes through the aperture into the uterus, 
and even into the vagina ; and, although the presence of the mesentery 
and the absence of pulsation should in such cases obviate the possibility 
of mistake, the sensation which the bowel yields bears such a resem- 
blance to the cord that an opinion might rashly be formed, which might 
lead, in practice, to the most disastrous results. Several cases, at least, 
have been recorded in which this blunder has been committed, with the 
most discreditable and unfortunate issue. 

As regards the mother, there is no risk whatever in a presentation of 
the funis. Experience has, however, shown that, of all possible presen- 
tations, not even excepting transverse cases, nothing is more fatal to the 
life of the foetus. Of all cases, and without any reference to the fact of 
assistance being rendered, it is certain that considerably more than one 
half of the children are lost, which is sufficient to show that the treat- 
ment or management of the cord in these cases, during labor, is necessa- 
rily one of the most important points which can possibly arise in the 



348 FUNIS PRESENTATION. 

course of practice. What we desire to effect is the protection of the cord 
from such pressure as may arrest the circulation, or, in other words, to 
avert, if it be possible, from the child, the danger of death from asphyxia. 
We have already seen, in reference to presentations of the pelvic ex- 
tremity, that the chief cause of increased mortality in these cases is 
pressure on the cord, and the same remark obviously applies with equal 
force to all cases of transverse or other presentation in which podalic 
version is practised. But, unless there should be prolapse, the danger 
is confined to the later stage of labor, during which the cord is subjected 
to pressure between the head and the pelvic walls. If the cord presents 
originally, the vessels are obviously subjected to a more prolonged and 
continuous pressure, so that the danger is considerably increased. When, 
in any case, the labor pains are frequent, violent, and of long duration, 
the chance of the child's life is small, unless delivery should be effected 
with unusual rapidity; but if, on the contrary, the pains are moderate, 
and of short duration, the foetus has time to rally, during the intervals, 
from the effects of the partial asphyxia which attends each uterine effort, 
and the cumulative effect of pressure is in a measure avoided. We must, 
however, even under the most favorable circumstances, look with serious 
apprehension, as regards the interests of the child, upon all cases of funis 
presentation, and we would do well to make a point in all such instances 
of informing the friends of the patient of the precise danger which we 
anticipate. Many circumstances, other than those already mentioned, 
modify the danger of individual cases, but in all, the continuousness and 
the degree of the pressure are the points upon which the gravity of each 
particular instance depends. If it should so happen, therefore, that the 
cord occupies a position in which it is exposed to comparatively little 
pressure, the chance of the case is greater ; and to this Naegele draws 
attention, and points out that when the cord presents with the head in the 
ordinary or first cranial position, the life of the child is much more likely 
to be spared if the funis lies towards the left sacro-iliac synchondrosis, 
the point at which it is least likely to be subjected to injurious pressure. 
Treatment. — Unless the case is otherwise abnormal, so as to call for 
operative interference in the interests of the mother, we of course leave 
to nature all cases in which we have unequivocal evidence of death of 
the child. We must, however, be careful in admitting want of pulsation 
in the cord as satisfactory evidence of the death of the foetus. If the 
cord be perfectly flaccid, and is examined continuously, during the oc- 
currence of several successive pains, without any pulsation being dis- 
cerned, we can have no doubt that all hope of the child must be abandoned. 
But, should the examination have been made hurriedly, during the oc- 
currence of a pain, we may be led to abandon a remediable case while 
there is yet hope, as it has frequently been observed, in such cases, that 
pulsation is for a long period arrested during the pains, and returns in 
each succeeding interval. As a rule, then, we should examine during an 
interval as well as a pain ; and it is only the continuous absence of pul- 
sation which is to be admitted as evidence of death. In almost all other 
cases, it is proper for the accoucheur to afford some assistance ; and in 
all, without exception, in which we presume that the child is alive, we 
must watch with constant attention the progress of the labor, so as to 



TREATMENT. 849 

afford at the proper moment such aid as may be applicable to the exigen- 
cies of the case. The indications of treatment which are to be observed 
are, either the entire relief of the cord from pressure, or its removal to 
where it will be subjected to the minimum of compressing force. While 
there are special cases in which little or no interference is required, or 
indeed justifiable, these form a very small proportion of the whole. The 
great majority, therefore, are those in which assistance of some kind or 
other is essential, and in many of them the skill and perseverance of the 
operator will be taxed to the utmost. The exact circumstances under 
which the displacement may occur, are of such infinite variety, that it 
were endless to attempt to lay down rules which may serve for the guid- 
ance of the operator in every case. There is, in point of fact, perhaps 
no contingency in the practice of midwifery in which sound judgment and 
self reliance are so essential ; but we are, nevertheless, enabled in the 
light of the experience of the most distinguished accoucheurs, to lay down 
certain general principles, upon which the management of presentation 
and prolapse of the funis is to be based. 

Should the cord be felt through membranes as yet unbroken, or 
through the uterine wall from the vagina, our treatment must be essen- 
tially expectant. It must not be imagined that integrity of the mem- 
branes is, under all circumstances, a guarantee that the cord is safe from 
injurious pressure, but so generally is this the case, that we are always 
bound to assume that upon nothing does the issue of the case so much 
depend as the prolonged retention of the waters. In cases, the termina- 
tion of which is intrusted to the natural efforts, this is, indeed, of para- 
mount importance; and, in all, we look upon the danger as imminent 
only, and not in actual operation, so long as the sac of the membranes 
prevents the prolapse of the cord. Nothing, therefore, can be more ob- 
vious than that we must exercise the greatest possible caution in such 
manipulations as we may deem necessary, with the view of subjecting 
the membranes to no such violence as might cause their rupture prema- 
turely. In a word, the preservation of the membranes is, in all cases in 
which we may be fortunate enough to discover the cord before their rup- 
ture, a point of primary importance. For this reason, also, it is far 
better to leave the presentation in doubt than to run any risk of rupture 
of the sac in our anxiety to be correct in our diagnosis; and, on the 
same ground, it stands to reason that no attempt should be made to re- 
place the cord at this particular stage, or even to guide it into those 
parts of the pelvis at which it will be exposed to least pressure. So long 
as the waters are retained, we may be confident that the cord is at least 
under more favorable conditions than could be afforded it by any reme- 
dial or operative procedure which we might think proper to adopt. In 
cases, therefore, in which the bag of the waters occupies the vagina after 
the termination of what is usually called the first stage, we do not act as 
we would under ordinary circumstances by rupturing the membranes ; 
but, on the contrary, we look upon the exceptional persistence of the 
membranes as of good augury in regard to the child in all cases in which 
we have already recognized the funis. The longer, in fact, the liquor 
amnii is retained, the shorter will be the final stage during which pres- 
sure more or less severe must be encountered ; and, other things being 



350 FUNIS PRESENTATION. 

equal, the less proportionally will be the risk to the life of the child. 
Persistence of the bag of the waters up to the moment at which the head 
is being born is perhaps the case of all others in which nature is most 
likely to secure a happy result. Such cases, however — and along with 
them may be classed instances in which the capacity of the pelvis is 
greater than usual — are not frequently met with ; but, when they do 
occur, we would be quite justified in simply watching the progress of the 
case, and only interfering when the symptoms become more threatening, 
or the conditions are such as to render prolonged compression of the cord 
a matter of certainty. 

The cases which are of most usual occurrence in practice, and those, 
too, which are the most favorable in their results, are where the head 
and the cord present together. In cases in which this complicated pre- 
sentation has been early recognized, when the membranes are complete 
and the os as yet but little dilated, it has occasionally been observed that 
the presenting cord has passed up out of reach, and the head descends 
alone as in an ordinary case. The possibility of such a satisfactory re- 
sult would of itself suffice to w^arrant us in endeavoring, by all means, to 
preserve the integrity of the membranes, but the result is not, as will be 
understood, one upon which we can, in any circumstances, depend. It 
has been asserted on good authority, however, that the conditions which 
render such an occurrence most likely are a small loop of cord, which is 
situated higher than usual and to one side of the os, and when the pro- 
jecting bag of the membranes is embraced by the lower segment of the 
womb with unusual force. When the cord descends along with the head, 
the risk is not so great to the child as in other complicated presentations 
of which the cord forms an element ; for, although the actual compression 
is greater, it is of much shorter duration than in breech and footling 
cases, and moreover, the danger may practically be said to be over so 
soon as the child's head is born. And, in addition to this, the possi- 
bility of successful reposition of the cord is much greater, on account of 
the more thorough adaptation of the spheroidal head to the cavity 
through w^hich it has to pass. If, on the other hand, we have to deal 
with the pelvic extremity, the cord, when replaced, is more likely to pro- 
lapse anew, and in every such instance the chance of prolonged compres- 
sion is much enhanced. No doubt, the actual pressure is, in the first 
instance, less than when it descends along with the head, but we must in 
such a case look forward, not only to a longer continuance of pressure, 
but, in addition, to the same ultimate compression from the head, at a 
period when, from long-continued interruption to the placental circulation, 
and by the operation of other causes, the life of the child is already in 
imminent danger. 

When that stage is reached at which the dilatation of the os is what 
we call complete, the membranes being as yet unruptured, it may occa- 
sionally be a matter of some difficulty to determine upon what principle 
we are to proceed in the management of the case. We know that the 
danger is greater in first than in subsequent pregnancies, and in mature 
than in premature deliveries ; but, beyond this we have nothing, in addi- 
tion to the facts already mentioned, which may guide us, further than a 
correct appreciation of general principles. If, upon examination, we 



TREATMENT. 851 

find that the cord still pulsates, we may, perhaps, use a little more free- 
dom with the finger, in order to ascertain the probable extent of the coil, 
and the exact nature of the presentation, but, with this exception, we 
must generally content ourselves by watching the progress of the case. 
As the head descends, we should try, if it be possible, to guide the cord 
towards the sacro-iliac synchondrosis which corresponds to the side of 
the cranium ; and in pelvic presentations it will also be proper to act 
upon the same principle by directing it to that synchondrosis which may 
correspond to the antero-posterior measurement of the breech, with the 
view, in each case, of placing the cord at that point of the pelvic circum- 
ference at Avhich the pressure will probably be least. 

With the rupture of the membranes, the cord will usually prolapse, to 
an extent proportionate to the size of the coil which precedes or accom- 
panies the presenting part. This is the stage which we will generally 
select to attempt the Reposition of the cord. With this object in view, 
we bring the points of the index and middle fingers to bear upon the coil 
in the interval between the pains, and thus endeavor to push it upwards, 
beyond the presenting part, into the cavity of the uterus. The process, 
when the coil is large, will resemble somewhat the procedure applicable 
to the reduction of a large hernia, by successively replacing portions of 
the cord until the whole has been reduced, remembering always that, to 
be effectual, reduction must be complete, and that, if ever so small a por- 
tion be left down, pressure may be as fatal as if we had never attempted 
the operation. But, with the actual reposition of the cord, our difficul- 
ties do not cease. The reduction of the prolapse may be easy enough, 
but the real difficulty consists in maintaining it in its position. The 
finger must, on this account, not be hurriedly Avithdrawn ; on the con- 
trary, we should, by continuous support, endeavor to retain it within the 
cavity until the child descends somewhat further, and forms, by its pre- 
senting part, a plug, which renders impossible, from its bulk, the renewed 
descent of the funis. The finger should, with this object, be cautiously 
removed during a pain, when the conditions referred to are, of course, 
present in the highest possible degree, so that, if the operation is suc- 
cessful, the labor will now be completed without any further risk than 
attends an ordinary case. For the reasons already stated, success will 
more frequently attend our efforts when the head of the child presents, 
as this part more thoroughly fulfils the condition of an effective plug. Un- 
fortunately, however, in a large proportion of cases, this manoeuvre will 
fail, and the cord will descend again and again, under the imjDulse of the 
uterine contractions. It was, probably, this unsatisfactory result which 
induced some noted authorities to recommend a more thorough method of 
reposition, by carrying the cord upwards towards the fundus of the 
womb, and endeavoring to suspend it over the limbs of the child, or at 
least to press it completely beyond the head, into the hollow formed by 
the neck. Both of these modes of procedure have been repeatedly re- 
sorted to, and sometimes with success ; but the difficulties which attend 
the operation in each case are such that, in the greater number of in- 
stances, we will fail utterly in our endeavor to maintain the cord in its 
improved position. 

This acknowledged and, in some instances, insuperable difficulty has 



352 



FUNIS PRESENTATION. 



given rise to much mechanical ingenuity. The object in view is to devise 
an instrument by means of which the funis may safely be returned to the 
upper part of the uterus, and, if necessary, retained there. Of such as 
have hitherto been invented, those which are the most simple in construc- 
tion seem to have succeeded best. Michaelis recommended that a laro;e 
sized gum-elastic male catheter should be used, to the eye of which the 
prolapsed cord is attached by a ligature, which is to be loosely drawn so 
as to avoid compression. The stylet is then introduced, and the catheter, 
carrying with it the cord, steadily pushed up in the direction of the 
fundus, where it may be left, the stylet being withdrawn, until the com- 
pletion of labor. The contrivance of Mr. Roberton is, with a trifling 
modification, the same as this. A simple piece of flat whalebone has 
been preferred by some, and is as simple and as convenient as the other. 
Perhaps if we were to express a preference for one form over another, 
that used by Dr. Braum for many years in his Klinik at Vienna might 
be selected as combining simplicity and efficiency in the highest degree. 
It is made of gutta-percha, and is used as is shown in the accompanying 
figure. It is about sixteen inches in length, and has, about two inches 
from the rounded extremity, an aperture of sufficient 
size to allow the passage of a loop of tape or worsted, 
which, after being carried round the cord, is brought 
over the extremity of the instrument, and is then 
pulled so as to grasp the cord firmly without sub- 
jecting it to dangerous compression. The apparatus 
is then pushed as high as is possible in the direction 
of the fundus uteri, and is allowed to remain until 
the further descent of the head in the pelvis pre- 
sents an effectual barrier to the prolapse of the 
cord. When we are convinced that this stage 
has been reached, the instrument is to be drawn 
down with a wriggling or shaking movement, by 
which the loop passes over the point, and the cord 
is left behind, while the whole apparatus is removed. 
Kiwisch effected the same purpose by fixing the 
point cut from a large catheter upon the extremity 
of an ordinary uterine sound ; and we have tried 
with success, an instrument of French construction, 
made of two parallel pieces of whalebone, of which 
the one slides upon the other, and has a sort of hook 
at the end by means of which the cord may be con- 
fined or released at will. The principle of the 
operation is in every case the same, and the varieties above mentioned 
are but a few of a large number which practical difficulty has suggested 
to different operators. We cannot, however, depend even upon the best 
of them for reliable and satisfactory results, and, in fact, we find that 
many experienced operators prefer the fingers in all ordinary cases ; 
while Tyler Smith informs us that even Michaelis abandoned his in- 
genious instrument for the use of the finger. Be this as it may, we 
should always try, when the fingers fail, what we can do with a reposi- 
torium, hastily constructed though it may be from such materials as are 




Braum's Kepositoriu 



GENERAL CONSIDERATIONS. 353 

at hand. The success attained by others is ample warrant for persevering 
efforts in this direction. 

The Postural Method of treatment has from time to time attracted 
attention during the last thirty years, and is associated chiefly with the 
names of Bloxam, Thomas of New York, and Dyce of Aberdeen. When 
this plan is adopted, the woman is placed upon her elbows and knees, so 
as to raise the pelvis above the level of the fundus uteri, and thus to take 
advantage of the law of gravity. That a certain amount of advantage 
is thus gained may be admitted, and it would appear that in practice the 
results have been in a measure satisfactory. We cannot, however, anti- 
cipate such results as the supporters of this procedure seem to claim for 
it. The posture in question will doubtless tend so far to the gravitation 
of the cord towards the fundus, but it must at the same time cause the 
head to retreat from the lower segment of the uterus, and thus remove 
what we are accustomed to regard as the most effectual barrier to pro- 
lapse, for, when a pain comes on, gravity is a mere feather weight in 
comparison with the power of uterine contraction. This may possibly 
explain why it has not been attended with more marked success. We 
should not hesitate to avail ourselves of the postural method in any case 
of difficulty, and it is quite possible that by combining reposition with 
the postural method, as has been suggested by Dr. Barnes, more favor- 
able results may ensue than have hitherto followed the use of either 
separately. 

So long as vigorous pulsation shows that the life of the child is not in 
immediate danger — and this we should also ascertain by auscultation of 
the foetal heart — we must not cease in our efforts to prevent the cord from 
descending into the pelvis along with the presenting part. M'Clintock 
and Hardy recommend that the woman should be made to lie upon the 
side opposite to that on which the protrusion has taken place. In addi- 
tion to the means above detailed, the expedients which have been devised 
are endless. Among these may be mentioned partial plugging of the 
uterine orifice, after reposition, by a piece of sponge ; and the inclosure 
of the coil of the funis, when unusually large, within a bag of some kind, 
the whole being then returned to the uterus and left there. 

It is universally admitted that a certain number of cases do occur in 
which reposition of the cord is a practical impossibility, or would be 
attended w^ith unwarrantable risk to the mother. Of such a nature are 
those cases — by no means of unfrequent occurrence — in which the acci- 
dent is not recognized until the head has already descended far into the 
pelvis. For the management of such conditions no definite rules can be 
given : all will depend upon the peculiar circumstances of each individual 
instance. We must be guided mainly by the following general considera- 
tions: — 

1. We must ascertain whether or not the child lives ; for it must be 
obvious that a negative answer to this question bars all further action on 
our part. When the cord, therefore, is flaccid and pulseless in the in- 
terval between the pains, and the pulsation of the foetal heart cannot be 
made out, we leave the case absolutely to nature, as we know that there 
is no danger to the mother, and we need no longer act in the interests of 
the child. 
23 



354 FUNIS PRESENTATION. 

2. No conceivable circumstances will warrant us in subjecting the 
mother to any considerable risk. Practically, in an uncomplicated case, 
she is perfectly safe, so that to endanger her on the mere chance, or even 
probability, of saving her child, would be w^orse than absurd. It is, per- 
haps, true that there is no operative procedure whatever which is not 
attended with some increase of risk, be it ever so little. But, from a 
moral as well as a practical point of view, we must draw the distinction 
between slight and serious risk, and upon this distinction treatment will, 
in many instances, be based. The principle must, however, remain a 
general one, for the gradations between the two extremes are infinite, and 
each case should thus be decided on its own merits, and in full view of 
the whole facts. 

3. When reposition is impossible, the simplest and safest mode of pro- 
cedure is to guide the cord, as has already been stated, towards that part 
of the pelvic wall where it is least likely to be subjected to severe pres- 
sure ; and, of all possible situations, the direction of that sacro-iliac 
synchondrosis which corresponds to the side of the child's head, if it be 
a cranial presentation, is perhaps the most favorable. The pulsations of 
the foetal heart, and those of the funis, must now be carefully watched, 
as representing the condition of the child, and indicating the approach of 
imminent danger; and upon these observations will chiefly depend our 
future course of action. So long as the pulsations are tolerably strong, 
we are justified in leaving the process to nature ; and in the case of a 
woman who has previously borne children, or in whom the pelvis is of 
larger dimensions than usual, the perilous stage of labor will often be 
safely passed, and the child born alive ; whereas in the contrary condi- 
tions of a primipara,or a narrow pelvis, the chances of a favorable result 
are comparatively small. 

4. When a failure of the circulation is indicated by the stethoscope or 
the finger, our course of action will be suggested, in a great measure, by 
the stage at which the labor has arrived. If, in an ordinary cranial 
position, the os is fully dilated, and the circumstances are otherwise 
favorable for the operation, we need have no hesitation whatever in ap- 
plying the forceps, and completing the delivery as rapidly as possible. 
In the case of the breech, the fillet or blunt hook may be used, with the 
view of expediting labor ; but these, or other operations, are only to be 
attempted when the conditions are generally favorable, and the risk to 
the mother is not great. 

5. The question of Turning, in funis presentation, demands, as a dis- 
puted point in obstetrics, some special attention. In the early part of the 
present century, the operation seems to have been held in pretty general 
esteem, but in more recent times the other and safer modes of operative 
procedure are, when practicable, usually preferred. It must not, how- 
ever, be supposed that the operation so warmly supported by Mauriceau 
is to be, under all circumstances, condemned. There are, in the first 
place, instances in which the operation must be performed in the interest 
of the mother, no less than in that of the child, and in respect of which, 
therefore, there can be no hesitation. Of this nature are cases of shoul- 
der presentation and placenta praevia, both of which conditions are apt 
to be complicated with descent of the cord. Here we scarcely take the 



TURNING. 355 

cord into consideration, so clear are the other indications ; or, if we do, 
it is only to admit it as of secondary importance, but, at the same time, 
as an additional circumstance which calls for speedy action, so soon as 
the proper period shall arrive for the performance of the operation under 
the most favorable conditions. But, while such cases are clear, it is 
otherwise when, in a cranial presentation, the question of turning offers 
itself for our consideration in the interests of the child alone, other modes 
of procedure being impracticable. The opinion generally entertained is, 
that under the circumstances to which we allude, we are rarely warranted 
in turning — a view which we believe to be, in the main, correct. That 
there are exceptional instances, however, in which, after other means 
have failed, we may be justified in performing the operation in question, 
we cannot dispute ; more especially, perhaps, in the case of primipame, 
where we may expect the pressure on the cord to be exceptionally great. 
There is, perhaps, no one point in regard to presentation of the funis 
which calls for more careful consideration and judicious balancing of the 
special circumstances of individual cases. A capacious pelvis, a yielding 
and moderately dilated os, and other conditions favorable to the operation 
itself, afford strong presumption that turning may be effected without any 
great risk to the mother. The period may not have arrived at which the 
idea of forceps can be entertained, and yet the child is in a state of im- 
mediate peril, so that the question may simply be : Are we to act, or to 
leave the child to its fate ? Here, experience, and the habitual caution 
which matured experience engenders, can be the only safe guides. AVe 
repeat, however, our conviction that cases do occasionally occur in which 
Ave would be justified in turning at once. We must not forget, while 
forming our resolution, that the operation does not necessarily, even 
under the most favorable circumstances, relieve the child from danger. 
For, the operation being performed, there is still the critical period of 
the passage of the head, during which, although everything be done 
which skill can achiev^e, the child, already enfeebled, may succumb from 
the renewed pressure on the cord. 



356 PREMATURE EXPULSION OF THE OVUM. 



CHAPTEE XXII. 

PREMATURE EXPULSION OF THE OVUM. 

Abortion; Definition of. — Cause fi : in General Health : from Reflex Irritation : 
from Diseases of the Ovum: from Action of Oxytocics: from Affections of 
Neighboring Organs: from Mechanical Violence. — Tendency to Repeated 
Abortion. — Symptoms at Various Periods. — Precursory Symptoms : Pains: 
Hemorrhage : to be distinguished from Delayed Menstruation . — Signs of Death 
of the Foetus. — Distinction to be draivn between " Threatened'" and ^^ Ineinta- 
ble" Abortion. — Retention of the Ovum. — Expulsion of the Placenta. — Treat- 
ment: Preventive: Prevention when /abortion Threatened. — Exp)ulsion to be 
Promoted when Inevitable. — 3Ianagement of Hemorrhage, and of the Pla- 
centa : Placental Forceps. — Treatment of a Woman after Abortion. 

Premature Labor. — Special Causes. — Treatment. 

Although the usual period of utero-gestation is about ten lunar 
months, the ovum may be expelled at any time by premature uterine 
action, the result of the operation of certain causes which we shall have 
to consider. Abortion^ in the sense now ordinarily attached to the term, 
is the name which is applied to the occurrence, when it takes place be- 
fore the eighth lunar month ; while Premature Labor occurs during the 
last three months of gestation. Many writers have confined the term 
" abortion" to the first sixteen weeks, and apply the word Miscariiage 
to the period between that and the twenty-ninth, but it is more conve- 
nient to adopt the simpler classification, which has the further advantage 
of allowing the familiar expressions "non-viable" and "viable" to be 
used, as applicable to the foetus, in connection with the periods of abor- 
tion and premature labor respectively. Miscarriage is a term familiar 
to women, and is used by them as synonymous with abortion in the 
wider sense in which we prefer to use the latter. 

Strictly speaking. Abortion may take place at any moment subsequent 
to conception. Should the one supervene immediately upon the other, 
or within the first few weeks, no symptom is likely to be manifested which 
would attract particular attention, and the blighted ovum in such cases 
might be as impossible of detection as the ovule which is thrown off at a 
menstrual period. If the ordinary catamenial period, in a woman pre- 
viously regular, should pass, her suspicions may be aroused ; but, if a 
discharge manifests itself in a few days thereafter, it is assumed that the 
period has been delayed, and this may be held further to account for the 
increase in the quantity, and of the pain which accompanies it, as com- 
pared with the symptoms attendant upon the ordinary menstrual flux. In 
point of fact, it is rare that the abortions of the first three or four Aveeks 
from the assumed date of conception attract such attention as to be brought 



CAUSES. 357 

under the notice of the medical attendant. Even during the course of 
the second month, the symptoms, although more distinct, may be over- 
looked ; and the woman, who is seized with considerable discharge, and 
uterine pains of a periodic character in the seventh or eighth week, may- 
be quite unaware that one of the clots which have been expelled contains 
the immature ovum. To the earliest abortions, the ancients gave the 
name of Uffluxio. When it is said, therefore, that abortion occurs most 
frequently from the eighth to twelfth week, we assume that the earlier 
abortions are not taken into couvsideration, for in truth we have no means 
whereby the number of the latter may be even approximately computed. 

The liability to abortion is undoubtedly greater in the earlier months 
of pregnancy, when the union between the chorion and the decidua is of 
lax character, so as to admit readily of hemorrhage into the space between 
them, with the result of cutting off the temporary communication which 
exists between the mother and child before the formation of the placenta. 
Fortunately, however, the earliest and most frequent abortions are not 
attended with much risk, as the ovum usually escapes entire ; and the 
hemorrhage which accompanies them, and which proceeds from the ves- 
sels of the decidua, is rarely such in extent as to cause any great alarm. 
In the latter part of the abortion period, — the sixth and seventh lunar 
months, — the symptoms manifested and treatment required are so analo- 
gous to what obtains at the full time, that few special directions are neces- 
sary for their proper management. It is quite otherwise, however, in 
regard to abortions which occur in the middle period, — say from the tenth 
to the eighteenth or nineteenth week. In these cases we have special 
dangers to dread, and, if possible, to avert, which separate this from any 
other period of abortion. These dangers are dependent upon special 
conditions which it is necessary carefully to observe and to understand, 
and the most important of them is the development of the vascular rela- 
tions between the maternal and foetal system, connected with the forma- 
tion of the placenta. 

The Causes of abortion must, before we o;o further, en^-ao-e our atten- 
tion. These are very numerous, and, being both general and local, may 
act in a very variable manner in inducing the premature action of the 
uterine fibres upon which the expulsion depends. Many obvious causes 
are to be traced to the general health or temperament of the mother. In 
so far as the familiar affections which so frequently attend early preg- 
nancy are concerned, — such as sickness, faintness, salivation, and the 
like, — and which, when extreme, are considered among the diseases of 
pregnancy, it has always been observed that these are very rarely the 
cause of abortion. The most common of all, — sickness, — is, even in the 
worst cases, little liable to be followed by premature expulsion. "It is," 
as Dewees says, " a remark as familiar as it is well grounded, that ver^ 
sick ivomen rarely miscarry ;" and when we see, in some instances, strong 
and apparently plethoric women miscarry, who have not been sick, we 
may feel inclined to share the general impression that sickness is a safe- 
guard, and possibly keeps down morbid irritability or rigidity of the 
uterine fibre. With these exceptions, however, it may be assumed that 
whatever deteriorates the general health of the mother is apt to produce 
abortion, or, at least, to place the woman in such a condition that she is 



358 PREMATURE EXPULSION OF THE OVUM. 

more susceptible to the influence of other causes which may then come 
into play. Any serious disease, whether acute or chronic, may be the 
direct cause ; and the general symptoms which accompany the original 
disease may be greatly aggravated by the occurrence in question. Many 
febrile disorders are extremely liable to lead to abortion, more especially 
smallpox, relapsing fever, and scarlatina ; and in too many of these cases 
there is a fatal issue. Of chronic diseases, none, perhaps, exercises a 
more marked influence than syphilis, which actually seems to poison the 
ovum, and is certainly associated, in many instances, with various forms 
of disease and degeneration, of which it is the seat. But it is not from 
the mother alone that such influences proceed ; for the ovum may be in- 
fected by the poisoned spermatic fluid of the male ; and, in some cases 
stranger still, it would appear as if the woman were a mere conductor of 
the contagious principle. As an illustration of this, in the case of small- 
pox, Mauriceau tells us that, shortly before he was born, his mother had 
the misfortune to lose the eldest of her three sons by this disease, and 
that in spite of her condition, as women will do, she tended him with 
constant and tender care. Mauriceau was born the day after his bro- 
ther's death, and, although his mother, neither then nor subsequently, 
presented the slightest symptoms of the disease, he had on his body at 
his birth, five or six undoubted variolous pustules. 

Reflex irritation, from a variety of sources, is one of the most frequent 
causes of premature expulsion of the ovum. The irritation may start 
from any part of the alimentary canal, and in those instances the nature 
of the case may be revealed by the existence of dyspepsia, diarrhoea, 
dysentery, or intestinal worms. In cases of protracted or injudicious 
nursing during pregnancy, it may have its origin in the nipple, by irrita- 
tion of the mammary nerves, as was conclusively shown by Dr. Tyler 
Smith. But, besides such distant sources of irritation, reflex action may, 
undoubtedly, be induced by direct irritation of the vagina, as in plug- 
ging ; or by irritation of the uterus itself, as is eff"ected, in fact, by the 
contact of a dead or diseased ovum. Illustrations of this variety of case 
might be indefinitely multiplied. " We may consider," says Tyler 
Smith, " abortion from reflex action as being, in some points of view, 
comparable with spasmodic asthma, or any other excito-motor disease. 
From certain irritating causes, an excitable condition of the excito-motor 
arcs concerned in parturition is induced. This state of excitability once 
produced, slight causes, which would, in healthy subjects, produce no 
disturbance whatever, are sufficient to produce morbid or spasmodic par- 
turition. This excitability is not suddenly reached. It requires that 
the nervous arcs, whether mammary, rectal, or other, should be irritated 
for a considerable time, when an excitable, charged, or polar state of the 
uterine nervous system seems to be produced. The period preceding a 
case of reflex abortion may be likened to the time preceding an epileptic 
attack." When the reflex irritation has its origin in the ovaries there is 
a tendency to the separation of the ovum at what would have been a 
menstrual period, — a fact which, taking the identity of the decidua and 
the mucous membrane as a matter of undoubted certainty, seems to con- 
firm the views of those who hold that menstruation involves a periodical 
discharge of that membrane. This particular cause seems, moreover, to 



CAUSES. 



359 



occur, for the most part, in those who have suffered, before impregnation, 
from some form of dysmenorrhoea. 

iVbortion is clearl}^ associated in some cases with certain diseases of 
the ovum. These have already been incidentally referred to in speaking 
of the diseases to which the embryo is subject. That fatty degeneration 
of the chorion and placenta has a marked and decided influence, seems 
at least to have been established beyond doubt by the admirable re- 
searches of Dr. Barnes. The particular variety of this degeneration 
which exercises the most undoubted influence upon the ovum in inducing 
premature expulsion consists in a metamorphosis of portions of the ma- 
ternal and foetal structures of the placenta. This may occur at any 
period of intra-uterine life, and the appearances presented by the cells of 
the decidua in the healthy and degenerated placenta are indicated in 
Fig. 132, where the two are similarly magnified and shown in juxtaposi- 



Fiff. 132. 






o/o 




Cells of Fatty and Healthy Decidua. 

tion. It is unnecessary to follow the minute and interesting series of 
changes which have been traced in reference to this form of degenera- 
tion. It seems, however, to be clearly proved that it is frequently in- 
duced by constitutional syphilis. The decidua, placenta, and other parts 
of the ovum are, like all other vital textures, liable to congestive and 
inflammatory affections, which may arrest the vitality of the foetus, either 
by inducing some of the various forms of degeneration, or by causing 
sanguineous effusion into the tissue of the placenta, which has occasion- 
ally been found to contain purulent deposits. When the blood effused is 
considerable in quantity, it constitutes what Oruveilhier has described 
under the name of Apoplexy of the Placenta, which, by interrupting the 
circulation, may cause death of the foetus, and, consequently, inevitable 
abortion, although the foetus may be retained in utero for a considerable 
time, while the degenerated structures of the ovum undergo further 
change. Any of the numerous diseases to which the foetus is liable may 
cause its death, and it is believed that twisting or knotting of the cord, 
either upon itself or round the neck of the child, may have a similar 



360 PREMATURE EXPULSION OF THE OVUM. 

result. Like the placenta and other tissues of the ovum, the cord too is 
subject to special diseases, in the course of which its function is de- 
stroyed. Besides this, the facts stated bj Mauriceau, Stein, and others 
seem to prove that the cord, when too short, may be so dragged upon as 
to endanger the integrity. 

Among the causes of abortion, we must not omit to mention those 
agents to which the name of Oxytocics has been given. The more 
familiar of them are the ergot of rye, borax, and savin, which, with some 
others, exercise an undoubted effect upon the muscular tissue of the uterus. 
The nature of their action is not thoroughly understood ; but it is certain 
that ergot, and probable that the others, exercise a marked influence 
upon the spinal cord. Through this channel, then, we may infer that the 
oxytocic influence passes, which incites the uterus to contraction. The 
uterus is however, not nearly so obnoxious to the action of these agents 
as when the organ is fully distended, either at the end of pregnancy, or 
from any other cause. A similar action is produced by carbonic acid, 
as has been abundantly proved by the records of cases of accidental or 
intentional poisoning. A precisely similar effect follows the retention of 
carbonic acid in the blood in asphyxia — a condition under which expul- 
sion of the ovum has very frequently been found to occur. Of the five 
hundred Arabs who were suffocated in the caves of Dahra, in 18-i5 — as 
is said, by the orders of the Due de Malakoff" — a considerable proportion 
were womon ; and of these many who were pregnant were found to have 
aborted ; and other instances of a similar nature have also been recorded. 
The same fact has been proved experimentally by the researches of Dr. 
Brown- Sequard, who further believes, as we have already stated, -that 
the oxytocic action of carbonic acid is the 'determining cause of labor at 
the full term, excitin '•, by the direct contact of venous blood, the irritable 
uterine fibre to contract. Emotional causes, such as joy, grief, anger, 
and the like, may produce an eff'ect precisely similar. In some cases of 
auto dafe, and other barbarous acts by which the victim perished at the 
stake, abortion has also taken place, partly, as is probable, the result of 
fear, and partly by the action of asphyxia. 

Certain affections of neighboring organs may produce the premature 
expulsion of the ovum. In many of these cases, it would seem as if the 
cause was a purely mechanical one. Tumors, adhesions which bind 
down organs that ought naturally to rise with the uterus, and anything, 
in fact, which may mechanically hinder the development of that organ, 
may act in the same way. Displacement of the uterus itself may act in 
the same manner ; and we have known cases of uterine retroversion, for 
example, in which abortion had occurred several times, and in which an 
ovum only reached maturity after the displacement upon which the abor- 
tion depended had been cured by appropriate treatment. 

Premature expulsion of the ovum may also follow the occurrence of 
accidents or mechanical violence of any kind, such as falls and blows, 
and these cases are important, as the symptoms which accompany abor- 
tion differ in them from the other cases previously detailed. Such causes 
may act in either of two ways : by an eff'ect produced on the organs or 
tissues of the mother, or by injury to the foetus which may cause its 
death. It has been denied by some authors that the latter is a possible 



CAUSES. 361 

cause, so admirably has nature provided against the effects of accident 
and shock. We do not speak now, of course, of extreme violence, but 
of SQch only as may afterwards operate as a cause of abortion. The 
following case, given by Cazeaux, is conclusive as to this : " A young 
woman, six months pregnant, while groping in the dark in her room, 
struck the abdomen violently against a table. During the night the 
movements of the child became suddenly very violent, then diminished, 
and the following day were no longer felt. Two days afterwards she 
was delivered of a dead child, which presented on the back an ecchy- 
mosis as large as the palm of the hand." Burdach gives the case of a 
woman who, in the sixth month of pregnancy, had received a blow on 
the lower part of the belly, of suflficient violence to fracture the forearm 
and the leg of the child : pregnancy went on to the fall time, and the 
fracture was found at birth to have united at an angle. The effect of 
such accidents as tell directly on the maternal parts is more obvious. 
Nothing, however, is more astonishing than the amount of violence which 
women may suffer with perfect impunity, in so far as pregnancy is con- 
cerned. Falls from windows, giving rise to severe contusions and frac- 
ture of the limbs, have repeatedly occurred to women who were pregnant, 
without causing abortion. The late Dr. Pagan used to tell of an instance 
in which his coachman drove right over a woman who was in the eighth 
month of pregnancy, inflicting upon her very serious injuries. His mas- 
ter, thinking that premature delivery must of necessity follow, caused 
frequent inquiries to be made, and found ultimately that the pregnancy 
was in no way disturbed, and that the woman was delivered of a healthy 
child at the full time. The slowness with which the uterus responds, in 
many instances, even to considerable irritation, is familiar to those who 
have had occasion to induce premature labor ; and the fatal result, in 
cases of criminal abortion, is, no doubt, mainly due to the amount of vio- 
lence which is resorted to, in the hope of exciting the contractions which 
milder measures have failed to induce. 

A disposition which is exactly the opposite of this exists in some wo- 
men, Avho, so to speak, abort upon the slightest provocation. That in 
many of those cases of habitual abortion, there is some anatomical or 
physiological cause upon which the phenomenon depends is more than 
probable ; and in all those instances in which there exists a mechanical 
impediment of any kind, it may follow impregnation periodically, almost 
as a matter of course. But, putting such aside for the moment, there 
are other, and by no means rare, instances in which we can only account 
for the repeated abortions by supposing that the uterus has contracted an 
inveterate habit. It is, perhaps, one of the most familiar observations in 
obstetrical practice, that a woman who has previously aborted is much 
more liable to miscarry. And, Avhen abortion has occurred in several 
successive pregnancies, we look upon each recurrence of that condition 
Avith considerable apprehension as to the issue of the case. In such, it 
is very generally observed that the tendency to separation of the ovum 
is greatest at a certain period of pregnancy ; and every accoucheur of 
any experience can recall cases in which successive ova were thrown off 
at exactly the same age, as calculated from the presumed period of con- 
ception. It would thus seem as if, in those cases in which no obvious 



362 PREMATURE EXPULSION OF THE OVUJU. 

cause can be detected, there was some perverted condition of the uterine 
fibre, as regards irritability, which prevented dilatation of the viscus 
beyond a certain point, analogous to what obtains in morbid irritability 
of the bladder, when the desire to micturate occurs long before even 
moderate distension has taken place. And in the latter case, too, habit 
has something to do with it, and resisting the call has, sometimes at least, 
a beneficial effect. In the case of the womb, however, voluntary resist- 
ance has no effect, and so the act goes on repeating itself if unchecked. 

If those above detailed embrace the chief, they are far from represent- 
ing all the causes which may possibly lead to premature expulsion. This 
would require a special treatise. Enough has, however, been said to 
enable us to apply the principles of treatment, which, without a knowl- 
edge of the etiology of the subject, we could b}^ no possibility attain. 

iSymptoms. — These vary somewhat according to the cause and the 
period of pregnancy. One of the most constant symptoms of all cases 
is pain, but in some instances the expulsion seems to be accompanied 
Avith little pain or even discomfort. In very early abortions, the pain 
may be no more than that which attends an ordinary menstrual period. 
The seat of the pain is usually the lumbar, sacral, and hypogastric 
regions, but it may extend to the groins and down the thighs. A trifling 
increase in the amount of the catamenial pain, and the presence of some 
solid masses along with the discharge, may be the only symptoms which 
attract attention, and are not unnaturally mistaken for those which ac- 
company a delayed menstrual period, when the ordinary functions of the 
parts are shortly resumed as before. At a more advanced period the 
symptoms are, as might be expected, more marked. The occurrence is 
then sometimes ushered in by a rigor, followed by an increase of tem- 
perature and in the frequency of the pulse, thirst, and sometimes nausea, 
even when this has not been present before. Other and more vague 
symptoms, such as palpitation, cold extremities, dimness of vision, and 
dark rings surrounding the eyes, have also been noticed. A cold uneasy 
feeling about the pubes — with more or less of weight in the same region, 
according to the size of the embryo — is looked upon, and with justice, as 
a characteristic and important sign. Lumbar pain and vesical tenesmus 
are also of frequent occurrence. If they should have been present, there 
is a cessation of what are recognized as the breeding symptoms : morn- 
ing sickness is no longer complained of, and the mammae usually become 
flaccid, although the pain in these glands is sometimes considerably in- 
creased. 

Those symptoms are in their nature precursory, but are soon succeeded 
by increase in the lumbar pain, which becomes periodic, and extends to 
the hypogastric region. If the fundus can be distinguished behind the 
pubes, it will now be felt to contract, indicating the commencement of 
uterine expulsive effort. If a discharge of an hemorrhagic nature has 
not previously taken place, that symptom will now be observed ; the 
amount of the discharge varying very greatly — depending, no doubt, on 
the extent to which the ovum has become separated from its attachments. 
An examination should now^ be made by the finger ; but this must be 
conducted with great caution, as any roughness of manipulation might 
make matters worse, by exciting the uterus to more energetic action, or, 



SYMPTOMS. 363 

possibly, by rupturing the thin sac which contains the liquor amnii and 
the embryo. The os and cer\dx -will be felt to be softened to an extent 
commensurate -with the period at which the pregnancy has arrived ; and, 
in addition, the os will be found more or less patent. 

In the earlier periods of pregnancy, we may have some little difficulty 
in making out whether the woman is pregnant or not. In many cases, 
therefore — in unmarried women for example — we must be very cautious 
in expressing an opinion on this point, however suspicious the symptoms 
may appear to be. According to Madame Lachapelle, the following 
points are of importance in establishing a distinction between the two. 
If the case be one of abortion, the os is more or less open ; hemorrhage 
usually precedes the pains, and gives them no relief ; but, on the con- 
trary, they become more severe as the case advances. If, on the other 
hand, the case be one of delayed menstruation, the os is nearly closed, 
or is at most very slightly opened : the pains precede the hemorrhage, 
and are diminished upon its occurrence, or may entirely cease when it is 
thoroughly established. These points are, no doubt, of importance, but 
are to be received in evidence with caution. Certain other rules are 
given with the view of enabling us to distinguish between a clot and an 
ovum in a digital examination at the os uteri, but these are of little if 
any practical importance, seeing that both a clot and the ovum may, and 
often do, present simultaneously. 

As the case progresses, and the rhythmical uterine contractions con- 
tinue and increase in energy, the os dilates still further, but the dilata- 
tion is often very tedious. At the period of pregnancy at which abortion 
occurs, the anatomical condition of the cervix is such, that its distension 
by the uterine efforts is effected under circumstances of comparative 
mechanical disadvantage. The conditions at least are widely different 
from the termination of the period of gestation, when the circumference 
of the external os is the only point against which the uterine efforts are 
directed; and, although the dimensions of the body which is to pass are 
to be taken into consideration, the wonder is that the difficulty of dilata- 
tion is not more universally marked. The rupture of the membranes is 
somewhat irregular in its occurrence, but if these remain intact, they 
will often be found to protrude in a manner similar to what obtains in 
labor at a more advanced period. In the course of the first few weeks, 
the ovum is generally expelled entire, which, indeed, is a most favorable 
occurrence, and accounts for abortions of that period being comparatively 
free from danger to the mother. When the membranes rupture, the 
embryo is expelled, and may be followed at a variable interval by the 
secundines. Or the latter may be retained for a longer period, to give 
rise to symptoms and difficulties which will require for their management 
all the skill and judgment which we have at our command. 

As a general rule, the death of the. foetus precedes the uterine con- 
tractions which cause its expulsion. In other cases, again, the foetus is 
born in such a condition as would seem to indicate that it had only 
perished while undergoing the process of expulsion ; and, in a third 
class, chiefly the result of accidents, it is expelled alive, and may move 
briskly for a few hours after its birth. 

It not unfrequently occurs that the symptoms which indicate the death 



364 PREMATURE EXPULSION OF THE OVUM. 

of the foetus are separated by a considerable interval from those which 
accompany the expulsive phenomena. When the former, the more im- 
portant of which have already been detailed, have been distinct and 
unequivocal, the sequelae, or external manifestations of abortion, are 
always to be looked for, usually after an interval of some days. When 
the woman has received an injury, or has otherwise been subjected to 
violence, the ovum may, if it be a very early abortion, be expelled 
almost immediately. If, however, it has attained any size, a certain 
interval must elapse, when, upon the death of the foetus, a similar but 
more gradual result will ensue, the mechanism of the expulsion being 
essentially the same as in the other case. It is in the cases in which the 
cause has been one rapid in its operation that the child is most frequently 
born alive. Whatever the cause may originally have been, if it acts by 
first destroying the life of the foetus, the latter plays the part of a 
foreign body, and, as such, excites the uterus to contract. " The living 
foetus," says Rigby, "obeys the laws of organic life ; the dead foetus 
those of gravity. When once the child has ceased to exist, it acts like 
any other mass of inanimate matter;" and this too is the reason why 
the feeling of weight is so frequent, and upon the whole so reliable a 
symptom in the more advanced periods at which abortion may occur. 

The symptoms of abortion call in every case for careful observation 
and attentive consideration. The most important practical point which 
may arise is the following : We shall suppose that no doubt is enter- 
tained as to the fact of pregnancy, while the symptoms are clearly those 
of abortion. But are the symptoms those of threatened abortion only ; 
or do they imply that the loss of the ovum is inevitable ? In the former 
case, w^e must do all we can to avert the expulsion; in the latter, we do 
all in our power to promote it: hence the importance, nay, the necessity 
of recognizing the special symptoms which enable us to distinguish the 
one class of cases from the other. If we are called to a case of abortion 
at the onset of the symptoms, we may assume that the loss of the ovum 
is seldom inevitable unless it is dead. Nothing, therefore, short of clear 
evidence of the death of the foetus will warrant us in abandoning all 
effort to save it. The danger depends for obvious reasons upon the ex- 
tent to which separation has taken place between the ovum and the 
uterus. Whether the ruptured vessels are decidual or placental, the 
maternal vascular supply for the nutrition and respiration of the foetus is 
more or less restricted by the rupture of the connecting vessels. No 
symptom, therefore, is of greater importance, than the amount of hemor- 
rhage which has occurred, as this may be held to indicate with tolerable 
certainty the extent of the separation and rupture of the tissues from 
which the blood flows. The quantity of the discharge is much more im- 
portant than its duration, so that, whereas, in the former case, we despair 
of the issue, or at least look forward with much apprehension, in the 
latter we will often meet with instances in which a moderate or trifling 
amount of discharge may persist for many days without the slightest 
effect being produced in arrestment of the process of gestation. Profuse 
hemorrhage, then, recurring, at short intervals, and accompanied with 
pallor, vomiting, and a tendency to syncope, indicates extensive separa- 
tion of the ovum, and proportionate gravity in the nature of the case. 



SYMPTOMS. 365 

Uterine contractions may not only be present, but may persist for a 
considerable time ; but we should never, on this account alone place the 
case in the " inevitable" category, as the symptoms sometimes subside 
spontaneously, and often do so under appropriate treatment. Rhyth- 
mical uterine contraction, however, is always a most alarming sign, and 
more than sufficient to cause anxiety ; but the significance of this as an 
isolated symptom will chiefly depend on the vigor and continuance of each 
successive pain. Of greater importance is the condition of the os. If 
this is agape, with some portion of the ovum already protruding, preven- 
tion is out of the question. Even although we fail to reach any portion 
of the ovum, if the os is widely patent, we recognize in that fact, evi- 
dence which, if not conclusive, is at least presumptive of abortion ; while, 
on the contrary, if the os is but slightly dilated, and the cavity of the 
cervix has as yet been but little encroached upon, our hopes of a favor- 
able issue are greatly strengthened. 

One of the worst indications possible is in the discharge of the liquor 
amnii, and in fact, when we can be sure that this has taken place, we may 
abandon all hope. Evidence of rupture of the membranes must, how- 
ever, be carefully sifted. The assertion of the patient on a point such 
as this may go for nothing. The observations of an intelligent nurse 
are, of course, of greater value ; but we must be cautious even then, as 
the possibility of hydrorrhoea and discharges from other sources must be 
admitted and disposed of before we can speak with confidence. If, with 
discharge of the waters, we liave a gaping os, profuse hemorrhage, and 
obliteration of the cervix uteri, the case may be given up, and our efforts 
directed into a new channel, with the view of expediting the process 
which, under more favorable circumstances, it would have been our duty 
to oppose. With intact membranes, closed os, trifling hemorrhage, and 
moderate or irregular uterine contractions, our prognosis may be favor- 
able, but is to be expressed with caution, as graver symptoms may at any 
moment supervene. 

In most cases of abortion, the expulsion of the ovum is slow, and it 
thus happens that the ovum, or a portion of it, is sometimes delayed for 
days in the orifice of the os. In so far as danger from hemorrhage is 
concerned, the death of the foetus some time prior to its expulsion is an 
advantage, as the utero-placental vessels atrophy, and there is thus little 
danger of hemorrhage — less even than in labor at the full time. Or, if 
the supply of blood be continued as before, it is misapplied, and result 5 
in the morbid development of the parts and the formation of a mole. In 
some cases, again, the death of the ovum is not followed by its expulsion, 
but it is retained for many weeks, or even months. At a very early 
period, the delicate tissues of the embryo are dissolved in the liquor 
amnii, and are said then to form a gummy solution. At a later period, 
it shrivels or dries up like a mummy, and may remain unaltered in this 
condition during the remainder of its sojourn in the womb. In other 
cases, it assumes the saponaceous and withered appearance, without any 
putrefactive odor, so graphically described by Devergie, which is appa- 
rently analogous to that variety of putrefactive change which the same 
eminent medical jurist has described under the name of adipocere. In 
these cases the woman may experience but little uneasiness, or may be 



366 PREMATURE EXPULSION OF THE OVUM. 

perfectly unconscious of anything unusual. She and her attendants may 
suppose that the ovum had passed undetected, until, after a long interval, 
a mass escapes from the vagina, with or without pain, an examination of 
which at once reveals the nature of the case. 

Apart from the danger arising from hemorrhage before abortion, the 
peculiar circumstances which attend the Expulsion of the Placenta are 
of the highest importance, and differ in many essential particulars from 
the corresponding phenomena of labor at the full time. "In all cases, 
the placenta is retained much longer after the expulsion of the child in 
abortion, than in labor at the full time." Thus wrote Burns, and his 
assertion is undoubtedly correct ; but we must here make a distinction 
between the different epochs of abortion. It is, as has already been 
remarked, to the middle term of the abortion period that our attention 
requires more particularly to be directed. At this time the placenta 
forms a close anatomical connection with the uterine tissues and with the 
maternal vascular apparatus, connections which are often to be severed 
only with the greatest difficulty. The uterine contractions suffice in many 
instances to burst the ovum and discharge the foetus, and when the cord 
breaks or is tied, uterine action ceases. But instead of a speedy recur- 
rence of the pains, and a natural and unaided- expulsion of the placenta, 
the uterus remains quiescent, the os closes, and the placenta, with the 
membranes, is retained, sometimes for hours only, but often for a much 
longer period, extending to eight or ten days, or even more. The absence 
of pain, and of other symptoms of importance, may induce the woman 
to believe that she is perfectly well, and we may on this account have 
some difficulty in convincing her of the necessity which exists for perfect 
rest. A return of the pains, after a very variable interval, marks a re- 
newed attempt on the part of the uterus to rid itself of its contents. If 
a considerable time should have elapsed, the os will have closed so firmly 
that a tedious process, which is conducted at great mechanical disadvan- 
tage, is necessary for its dilatation. This process is often attended with 
alarming hemorrhage, as it is only now that the uteroplacental vessels 
are being severed, and this hemorrhage may only cease upon the expul- 
sion or extraction of the placental mass. 

Should there be no effort at expulsion, the placenta will usually be- 
come the seat of putrefactive changes, a condition which will be mani- 
fested by the occurrence of a dark and fetid discharge. Under the 
influence of this, the structures may be broken up and discharged piece- 
meal ; but the process is always tedious, and may be accompanied by 
low fever, in consequence of which the woman may become reduced to a 
condition which may excite considerable alarm, and there is of course the 
danger of Avhat fortunately does not often occur in such cases, viz., 
blood poisoning through the uterine veins. A similar condition, as re- 
gards discharge and general symptoms, may also supervene in those 
instances in which the membranes rupture, and the foetus, as well as the 
placenta and membranes, is retained, the access of atmospheric air in 
this as in the former case giving rise to putrefactive decomposition. It 
is said that, in some cases, absorption of the placenta occurs, and in this 
way the uterus may get rid of its contents. " In cases of twins," says 
Burns, " after one child is expelled, either alone or with its secundines, 



PREVENTIVE TREATMENT. 867 

the discharge sometimes stops, and the woman continues pretty well for 
some hours, or even for a day or two, when a repetition of the process 
takes place, and, if she has been using any exertion, there is generally a 
pretty rapid and profuse discharge. This is one reason, amongst many 
others, for confining women to bed for several days after abortion. The 
second child may, however, be retained till the full time." 

There is one other point which is of great value in estimating the 
gravity of the symptoms supposed to be due to retained placenta after 
abortion. The accoucheur may have had no opportunity before this of 
personally ascertaining the facts of the case, and may therefore be 
grievously misled by the details with which he is furnished. Nothing is 
of greater importance in the earlier abortions than that all clots and solid 
matters which escape should be carefully preserved for examination ; but, 
unfortunately, this is seldom done. We may thus be in no small mea- 
sure perplexed by the doubt Avhether the imperfectly formed placenta 
and embryo, or the placenta alone remains behind. The history which 
we may receive from the woman or her attendants must therefore be 
cautiously received, as quite circumstantial details are sometimes given 
of the expulsion of the embryo, and yet the issue of the case may show 
that the presumed ovum can have been nothing but a clot, the layers of 
which may have appeared to resemble the membranes which inclose the 
product of conception. Important information is almost always to be 
derived from a careful inspection of the discharges, and all clots should 
be washed and carefully examined with a view to the discovery of shreds 
of membrane, fragments of placenta, or structures which show, more un- 
equivocally still, the nature of the case. 

Treatment. — The treatment of abortion may be arranged under two 
heads : 1st, to prevent it when this is possible ; and, 2d, to favor expul- 
sion when this is inevitable, — under which we may include the manage 
ment of the placenta. 

The Prevention of abortion may, as a practical question, be presented 
for our consideration under various forms. In the case of the woman 
who has aborted on several occasions successively, our treatment is, in 
the strictest sense, preventive, and must be commenced long before actual 
symptoms of abortion are manifested. In regard to this particular branch 
of treatment, while there are certain general principles upon which the 
ma^iagement of all cases must be based, there are, at the same time, 
special considerations, which must not be lost sight of, as applicable to 
individual cases. A careful investigation of the causes which may have 
induced, on former occasions, the premature expulsion of the ovum, will 
sometimes point to the special considerations alluded to. There is a 
great tendency, in these cases of repeated abortion, to the separation of 
the ovum at the same period of gestation. This law operates with great 
force in cases in which there is no cause in the constitution of the mother, 
nor disease in the ovum, to which it can be attributed ; so that, in some 
instances, the uterus actually seems, as it has often been expressed, to 
have contracted a habit of periodical abortion. The general principles, 
then, which guide us have their origin in this fact, and the treatment of 
every case is more or less based upon it. The object is, if it be possible, 
to tide over the period of former abortions ; and, when this can be sue- 



368 PREMATURE EXPULSION OF THE OVUM. 

cessfully effected, the pregnancy will often progress, and reach the full 
time, without the occurrence of a single bad symptom. If we can only 
succeed in breaking the habit — be the ultimate result of the pregnancy 
what it may — we have achieved something in the way of success ; and 
we have known more than one instance in which the result of treatment 
was, in the first place, to transfer the period of abortion from the third 
to the fifth month, and on the occasion of the next pregnancy, a repetition 
of the same treatment Avas attended with the most satisfactory results 
possible. 

In effecting our object, in the circumstances now under consideration, 
rest must be placed first among the remedial agencies in which we may 
trust. The strictness with which we enjoin rest will depend, in a great 
measure, on the number of previous abortions, and the extent to which 
preventive measures have already been adopted. In the worst,, or most 
obstinate cases, nothing will do short of absolute confinement to bed, in 
the recumbent posture. When the woman has aborted but once or 
twice, it is by no means necessary that absolute rest should be so strictly 
enforced ; but, in every case, the chief care is to be directed to the 
period at which previous accidents occurred. Something Avill depend on 
the effect which want of exercise may have on the general health, and if 
any deterioration should be observed in that direction, it becomes a 
matter of consideration, whether we are not doing more harm than good 
by the course we are adopting. And, moreover, there are many cases 
in which the circumstances of the patient render it, for her, an impossible 
matter to abstain from all physical exertion ; and there are other cases, 
again, in which we have to take into consideration the amount of energy 
w^hich exists in the temperament of the patient, as it is clear that the 
w^oman who leads a life of irrepressible energy will require more restraint 
than one who is languid and disinclined to exertion. There are other 
causes which, no less than physical exertion, must be avoided, as far as 
is practicable. Among them are emotional causes, and any local irrita- 
tion which might, by any possibility, act reflexly in the direction of the 
uterus. Irritations of the skin, bladder, or alimentary canal, are of this 
nature, and even such distal irritation as toothache has been known to 
act in a similar manner. A careful inquiry into the circumstances which 
attended former abortions should always be made ; and, if it is found 
that diarrhoea, vesical irritation, or any similar affection, was a prominent 
symptom, as these sometimes are, it will be proper narrowly to watch, 
and if necessary to rectify, the function which may thus have been dis- 
turbed. Separation a thoro is in most cases proper, and in some indis- 
pensable ; and, if necessary, the patient should be cautioned against the 
effects of tight lacing. 

In women who are constitutionally weak, or apparently cachectic, a 
tonic treatment is, in addition to the precautions just mentioned, held to 
be proper. Some Spas, chiefly chalybeate, enjoy a certain reputation 
in such cases, and tepid or cold sea-bathing, both before and after con- 
ception, was strongly recommended by Mr. White, of Manchester. But, 
while the general health of the woman is thus attended to, we must not 
overlook any special constitutional causes which may be in operation. 
The most important of these is undoubtedly syphilis, and the best chance 



PREVENTIVE TREATMENT. 369 

of success in dealing with such cases is — whether the mother or father, 
or both, be aifected — to bring them gently under the influence of mercury 
before coitus is again permitted. An examination of the structures ex- 
pelled in former abortions may seem to call for certain special means of 
treatment in addition to the general course of procedure above indicated. 
Diseases of the placenta or membranes act upon the foetus mainly by 
interfering with the oxygenation of the blood. It has been proposed, 
therefore, that an attempt should be made to introduce a superabundance 
of oxygen into the maternal blood — an indication which it has been 
attempted to fulfil by inhalations of oxygen, or by the exhibition of such 
substances as contain a large proportion of oxygen in a state of feeble 
combination. It was with this object that Dr. Bower prescribed nitric 
acid, and Sir James Simpson the chlorate of potash. In the case of 
other diseases of the ovum or foetus, such as meningitis or peritonitis, 
mercury and other drugs have been prescribed on an analogous principle, 
in the hope of affecting the foetus through the maternal circulation, but 
so many difficulties are in the way of correct diagnosis in such cases, 
that little can be hoped for in the way of successful treatment. Indeed, 
with the single exception of the treatment of syphilis by mercury, we 
can place but little reliance on the medicinal treatment of habitual abor- 
tion, beyond what is administered with the view of giving tone to the 
system, or allaying constitutional disturbance. We must not, however, 
even where nature seems to defy us, in any case despair of success. Dr. 
Young of Edinburgh tells, in his lectures, of a case in which the patient 
actually miscarried thirteen times, and yet bore a living child the four- 
teenth time. In the most obstinate cases, a year's marital separation 
should be enjoined. 

The prevention of abortion extends, although in a somewhat different 
sense, to the treatment of cases in which the symptoms of impending 
H^bortion have already manifested themselves. Having taken due cogni- 
zance of the symptoms which enable us to decide whether or not the loss 
of the ovum is inevitable, and being persuaded that there is room for 
hope, the eff'orts of the accoucheur will chiefly be directed to the expul- 
sive contractions of the uterus. The success of his treatment will in fact 
depend upon the power which the remedies he may employ will exercise 
upon this function of the uterus. Should any source of irritation exist, 
he must at once attempt to remove or to allay it. The most perfect 
quiet of body and mind is more important perhaps than anything else. 
The patient should lie on her back on a hard mattress, and be kept cool. 
She should change her position as seldom as possible, for any exertion 
however slisiht will often be attended with a o;ush of blood. Her food 
should be light and easy of digestion ; and not only stimulants, but 
animal food should in most instances be forbidden to her. Hemorrhage 
is one of the alarming symptoms which we desire to arrest if it be possible, 
and on this account it is well to give the food cold, or at least cool. 
Caution must, however, be exercised in the use of ice, either internally 
or externally, for if, as is sometimes done, all the food is iced, and, in 
addition, cold affusion and injection resorted to, we may excite reflex 
action of the uterus, and thus defeat our ultimate object, although we 
may arrest the hemorrhage. With the view of arresting uterine action, 
24 



370 PREMATURE EXPULSION OF THE OVUM. 

nothing can be compared with opmm, which is indeed our sheet anchor. 
This has succeeded even in cases where the discharge was alarming, and 
the OS open to a considerable extent. To secure the full advantage of 
its sedative action, it must be given in full doses, so that forty minims of 
the Liquor Opii Sedativus in two doses, at an interval of twenty minutes, 
may be given in most cases without the slightest hesitation. This pre- 
paration has, we believe, the advantage which Rigby claimed for it over 
the other preparations of opium, that its sedative effect is more sure, and 
that it produces less irritation and derangement of the stomach and 
bowels. In other cases, again, in which it may be inadvisable to give 
opium by the mouth, an ordinary enema of starch with a drachm of 
laudanum will be preferred ; and, in point of fact, the possibility of 
having a local in addition to a constitutional effect, when it is administered 
in this way, will probably cause many to make choice of the method. 
Chloral, by the mouth or by injection, has also been employed with suc- 
cess. We must never despair so long as a chance remains of saving the 
ovum, bearing in mind that evidence of the death of the foetus is an im- 
mediate warrant for suspending all operations which have for their object 
the retention of the product of conception. It is a safe and good rule, 
however, that so long as we are not sure that the foetus is dead, we should 
act as if it were living. 

When violent pains, profuse hemorrhage, discharge of the liquor amnii, 
and progressive dilatation of the os, shoAV that abortion is inevitable, the 
treatment differs widely from the above, as the object of it now is to pro- 
mote instead of to prevent expulsion. In the course of this process, 
however, there are so many steps to be gone through, that it often requires 
great nicety and discrimination to conduct a case to a successful issue, 
which implies the safety and speedy recovery of the mother. In the 
first three months, the less we interfere the better. For, in these in- 
stances, as has been seen, the ovum often escapes entire, which is the 
most favorable occurrence possible ; while, if we interfere too much in 
the way of careless manipulation, we run the risk of rupturing the mem- 
branes, discharging the liquor amnii, and thus causing a protracted re- 
tention of the whole or part of the ovum. The only symptom which is 
likely even thus early to call for energetic treatment is hemorrhage. It 
is unusual at this period for loss of blood to be a cause of much danger 
or alarm ; but if it should be so, we should not hesitate to plug the vagina. 
Of the various modes of plugging, none is more simple or more effective 
than that which is recommended by Dr. Dewees. He advises that a piece 
of soft sponge, of sufficient size to fill the vagina without producing un- 
easiness, should be wrung out of pretty sharp vinegar, and introduced 
into the passage up to the os uteri : the blood in filling the cells of the 
sponge coagulates rapidly, and forms a firm clot, which completely seals 
up the vagina without producing any of those unpleasant effects which 
follow upon the insertion of a napkin rolled up for that purpose. There 
is this to be said in reference to the action of the plug, that while it may 
be looked upon as universally applicable in all cases of alarming hemor- 
rhage, when all hope of saving the ovum has been abandoned, we should, 
if possible, avoid it in all other cases. It is an undoubted source of re- 
flex contraction, and may thus precipitate labor in a hopeful case. If 



MANAGEMENT OF THE PLACENTA. 371 

properly applied, the plug may be left for a considerable time without 
interference, and may often be expelled with the ovum. If removed, and 
the hemorrhage continues while the os is still contracted, there is no course 
open to us but to renew the plug, and this may always be done with the 
less hesitation, as it is Avell known that the risk of internal hemorrhage, 
leading to accumulation in the womb during the period of abortion, is 
v€ry trifling, and has rarely been observed earlier than the sixth month. 

As in the case of other hemorrhages, astringents are frequently given 
in abortion, sometimes with good effect. It is, however, in the earlier 
abortions in which this is most marked, when acetate of lead, gallic acid, 
and the mineral acids, may often be given with advantage. The more 
advanced the pregnancy, the less can we rely on ordinary astringents ; 
so that we must then resort to oxytocics, with the view of exciting ute- 
rine contractions of such force as may expel the ovum, or such portion of 
it as may be retained. A simple enema, or one containing turpentine, 
will often serve as a powerful incentive to uterine action. If the abortion 
is one of the sixth month, we may sometimes be justified when the hem- 
orrhage is alarming, in rapturing the membranes, as in an ordinary case 
of accidental hemorrhage towards the end of pregnancy — a mode of 
treatment which was recommended by Puzos. More probably, even then, 
we would make choice of plugging, in preference to a mode of procedure 
which must even further remove any small chance of saving the ovum 
which might exist. 

It is the Expulsion of the Placenta, however, in regard to which the 
greatest difficulty is often incurred. If that period of pregnancy has 
been reached at which this organ is distinct, the main difficulty would 
seem to arise from the firm anatomical connection which subsists between 
the uterus on the one hand, and the placenta on the other. If, therefore, 
the whole ovum is not expelled entire, as is usual in the early Aveeks,the 
effect of the uterine contractions will probably be to rupture the mem- 
branes, and discharge the embryo or foetus through the cervix, which has 
been sufficiently dilated for this purpose. The action then ceases, the os 
closes, and the placenta is retained : so that here the analogy between 
abortion and labor at the full time ceases. 

This being the state of matters, two courses are open to us — to remove 
the placenta after forcible dilatation of the os, or to leave the case to 
nature. Aro;uments have not been wanting; in favor of both modes of 
procedure, and it is sometimes a matter of no small difficulty to decide 
which plan we should adopt. All admit that a complete separation and 
discharge of the placenta and membranes is of the first importance, and 
it is not to be doubted that the retention of any portion of the placenta 
or membranes is a condition which, with good reason, gives rise to no 
little anxiety. Probably the most judicious method of treatment is, in 
all cases, to remove the retained structure at the time if this can be 
easily effected ; but if, on the other hand, there is a retained placenta 
and a rigid os, it is on the whole safer to wait for a time than at once to 
operate, provided the symptoms are not alarming. When, after an in- 
terval of hours or days, as the case may be, hemorrhage recurs, with 
pains more or less distinct, indicating further separation of the placenta 
and renewed uterine efforts, we must carefully observe the symptoms 



372 



PREMATURE EXPULSION OF THE OVUM, 



Fig. 133. 



which are being developed, and manage the case accordingly. The 
hemorrhage may be so profuse as to require the plug, while we wait for 
the dilatation of the os. While this process is slowly being effected, we 
may find that a portion of the placenta occupies the cervix, and can al- 
ready be reached with the finger. Great caution should here be exer- 
cised; and, if the hemorrhage is not alarming, it may be set down as a 
rule, that we should abstain from interference until there is some clear 
evidence of entire separation of the placenta, or until the os has reached 
a stage of more advanced dilatation ; and even then, should all be going 
on favorably, it will be better to leave the process to nature, than to 
interfere, with the vicAV merely of accelerating a pro- 
cess which nature is satisfactorily effecting. If we 
interfere prematurely, we incur the danger of remov- 
ing from the os a portion only of the placenta, after 
which the closure of the os may again occur ; and, 
besides this, the flow of blood may thereby be actually 
increased, as the portion removed may have, served as 
a natural plug. 

The Symptoms which call for more prompt measures 
are, in addition to profuse and repeated hemorrhage, 
fetid discharges, and febrile symptoms, especially if 
the latter may seem to indicate septicaemia. Then 
we should act without hesitation, as the risk of allow- 
ing septic absorption to go on is greater than that 
which attends even forcible dilatation of the os, so 
that the immediate removal of the placenta becomes 
our first object. With this in view, the finger is to be 
cautiously passed round the protruding portion, and, 
if necessary, another finger may be introduced into 
the OS. If we can thus succeed in getting a hold of 
the placenta upon which we can rely, it may be ex- 
tracted entire ; but a rude or unskilful mode of manipu- 
lation may entirely frustrate our efforts by leaving behind a portion of 
what we wish to extract whole. It is impossible to lay down rules for 
the skilful performance of this manoeuvre, which can only be taught by 
experience ; but we have no doubt that more reliance is to be placed upon 
the fingers than upon instruments, as a general rule. Levret recom- 
mended the injection of a pretty powerful stream of warm water, by 
means of a syringe, into the uterus, on the same principle as is adopted 
for the removal of wax or foreign bodies from the ear ; but the danger 
of intra-uterine injection, which modern practice has revealed, will pro- 
bably deter most operators from adopting this plan. The placental for- 
ceps was devised by the same authority with the object of grasping and 
removing a retained placenta. Since then many varieties of this instru- 
ment, some of them most ingenious, have been constructed. Among 
others. Dr. Dewees recommended a wire crotchet, which he had used 
with good effect ; and this, variously modified, has been not unfrequently 
employed since his time. It must be confessed, however, that, whatever 
ingenuity may be exhibited in the construction of these, the fingers are 




Placental Forceps. 



TREATMENT AFTER ABORTION. 373 

almost always to be preferred ; and, if instruments are tried, they should 
only be used as auxiliary to the safer means of ordinary manipulation. 

In a certain number of cases benefit is derived from the use of ergot, 
and we need never hesitate to employ it ; but we must not count too much 
upon its action, for the smaller the bulk of the uterine contents, the less 
is it to be relied upon. 

Under ordinary circumstances, abortion is attended with but little risk 
to the mother, and the cases in ^vhich her life is placed in jeopardy are, 
therefore, relatively rare. Without taking into consideration the numer- 
ous instances in which abortion actually takes place, and is never recog- 
nized as such, this termination of pregnancy is of such frequent occur- 
rence that the difficulties and dangers above described are only too 
familiar to the busy practitioner. Dr. Whitehead of Manchester made 
this a point of special investigation, and found that out of two thousand 
pregnant woman, who had applied to the Manchester Lying-in Hospital, 
the total number of their abortions amounted collectively to one thousand 
two hundred and twenty-two. Thirty-seven out of every two hundred 
mothers had aborted before they had reached the age of thirty, and 
among those of a more advanced age the proportion of abortions was 
very much higher. It is, in point of fact, a rare thing for women to pass 
the greater part of the child-bearing epoch in wedlock, without having 
aborted once, or oftener — which, along with the facts above cited, will 
suffice to show how enormous must be the loss of foetal life in the aggre- 
gate. 

The treatment after abortion is a question of considerable importance ; 
but, unfortunately, it is often a difficult matter to persuade a woman of 
the necessity which exists for the exercise of ordinary prudence and 
care. Under favorable circumstances, all that may be necessary is con- 
finement to bed for a few days, and avoidance of fatigue and exertion for 
some time thereafter ; but, in other cases, more strict treatment may be 
necessary. Should retained fragments of placenta give rise again to 
hemorrhage, the patient must not be permitted to rise until all trace of 
this has ceased ;^ and, if her general health has materially suifered, a 
course of chalybeate tonics, change of air, tepid sea-baths, and the like, 
must be resorted to, with a view of restoring the health. The great 
danger accruing from neglect of these precautions is not so much to be 
evinced in immediate eftect as in the more remote results ; and we are 
convinced, from long experience, that no more fruitful source of men- 
strual disorder or of chronic uterine disease exists, than what arises 
from a want of due precaution at this critical period of a woman's 
existence. 

But little of a special nature remains to be said of Premature Labor, 
which occurs only during the last three months of gestation — at a period, 
therefore, at which the child is held to be "viable," A vulgar idea 
very generally prevails, that children born at the eighth month are 
reared w^ith more difficulty than those which are prematurely expelled at 

' A peculiar formation lias been described hy Scanzoni, Braun, and otlxers, under 
the name of Placental Polypus. In these cases, the placenta remains in permanent 
connection with the uterine wall by a pedicle through which its vitality is main- 
tained. It may be removed by the ecraseur after dilatation of the os. 



374 HEMORRHAGE BEFORE DELIVERY. 

the seventh ; but careful observation has clearly shown, what reason and 
analogy would have led us to conclude, that the further removed from 
the natural term of pregnancy is the period of delivery, the less chance 
is there of rearing the child. Many of the causes which have been 
enumerated as inducing abortion may also operate similarly at this more 
advanced period of pregnancy, but there are undoubtedly other special 
causes which may also be mentioned. The most important of these latter 
is over-distension of the womb, from whatever cause this may arise. 
Plural pregnancy, dropsy of the amnion, and hydrorrhoea, are all causes 
of this nature ; and the immediate result of their operation is that the 
uterus attains, at a period much earlier than is usual or normal, that de- 
gree of distension which is characteristic of completed gestation. The 
symptoms and treatment of premature labor differ in no essential par- 
ticular from what obtains at the full term. If the dilatation of the os is 
somewhat tardy, a commensurate mechanical advantage is gained in the 
ease wdth which the foetus passes through the parturient canal. There 
is however, without doubt, a greater tendency to retention of the placenta, 
although in a much less degree than in the course of the abortion period ; 
and, the nearer the delivery is to the natural term of gestation, the more 
strictly identical are the symptoms with those of mature birth. 



CHAPTEK XXIII. 

HEMORRHAGE BEFORE DELIVERY. 

'•'■ Unavoidable'" and ^'■Accidental" Hemorrhage. — Placenta Pr^evia; Centred 
and Lateral : Original Idea as to the nature of: Views of Boeder er and Righy. 
— Causes of Placental Presentation. — Symptoms : Hemorrhage before and 
during Labor: Examination from the Vagina. — Occasional Termination by 
Expulsion of the Placenta., loith Cessation of Hemorrhage. — Symptoms and 
Termination of ^^ Lateral" Variety. — Treatment: General Measures : Use of 
the Plug or Tampon: Evacuation of the Liquor Amnii by Puncture of the 
Membranes or Placenta. — Turning in Placenta Prcevia : Passage of the Hand 
through the Placenta at one time Practised : Usual Method of Operation. — 
The Bi-Polar Method. — Artificial Extraction of the Placenta: Simpson s 
Statistics. — Partial Separation of the Placenta: Barnes's Views. — General 
Conclusions as to IVeatment. — Accidental Hemorrhage ; more serious 
than is generally supposed. — Site of the Placenta. — Symptoms. — Treatment. — 
Use of Styptics in both Forms of Hemorrhage. 

While hemorrhage prior to delivery is, as has just been shown, the 
rule in cases of premature expulsion of the ovum — a rule which indeed, 
at certain periods of abortion, admits scarcely of an exception — it is 
otherwise with labor at the full term. With the exception of the trifling 



PLACENTA PREVIA. 375 

hemorrhao;ic discharo;e constitutino; at the termination of the first stao-e, 
what the midwives call a "show," any loss of blood which precedes the 
birth of the child when mature, is in its nature abnormal. In practice, 
a certain number of cases are found to occur in which, in consequence of 
abnormal conditions, a serious loss of blood occurs before birth, so serious 
as in many instances to imperil the life both of the mother and her child. 
All cases of hemorrhage before labor do not, however, as will clearly be 
shown in the sequel, depend on the same cause ; and, in consequence, the 
treatment applicable to each varies in relation to the cause which pro- 
duces it. Dr. Rigby, in his admirable essay on this subject, published 
now nearly a hundred years ago, divided cases of hemorrhage which oc- 
cur in the last three months of gestation into those which are " unavoid- 
able" and those which are "accidental." Of the two, the former is the 
more important, and is familiarly known under the name of Placenta 
Prsevia ; while the accidental form is due to the operation of causes which 
are similar in their nature, and in their mechanism, to the discharges 
which occur in abortion. 

Placenta Prcevia^ or Placental Presentation, as it is otherwise termed, 
implies that the placenta, instead of occupying its usual site in the neigh- 
borhood of the fundus uteri, is the lowest or most dependent part of the 
uterine contents, and occupies, wholly or partly, the passage through 
which the child has to pass. When it is attached to the entire circum- 
ference of the cervix, it is called " complete" placenta prsevia, or Pla- 
centa Centralis; while, if it is adherent to a portion only of this area, it 
is usually designated as " partial" placenta pra^via, or Placenta Lateralis. 
Such peculiar situation of the placenta necessarily involves its detach- 
ment from the subjacent uterine tissues with which it is in contact. This 
may take place, either gradually, in proportion as the lower segment of 
the uterus expands in the latter months of pregnancy, or, more suddenly, 
when the mechanism of the first stage of labor tears asunder those at- 
tachments, in the course of the uterine contractions which eifect dilata- 
tion of the OS. In either case, the hemorrhage from gaping vessels is in 
the strictest sense of the term "unavoidable," as it is impossible for the 
child to be born without hemorrhage of the most alarming description. 
There are, on this account, few of the dangers of midwifery which the 
accoucheur dreads more ; and Naegele was probably right when he said 
" that there is no error in nature to be compared with this, for the 
very action which she uses to bring the child into the world, is that by 
which she destroys both it and the mother." 

The idea entertained by the ancients, and which (Avith the exception 
of Portal and Gilford) was taught in all works on midwifery down to 
about 1T66, — when Roederer's " Elementa Artis Obstetricise" was pub- 
lished — was that in these cases the placenta was originally attached at 
its usual site, and that it only fell down to the lower part of the uterus 
after it had been entirely separated. Roederer, in the work above re- 
ferred to, gave as complete and succinct a description of placental pre- 
sentation as is to be found in any modern work on obstetrics, and drew, 
moreover, a distinction between central and lateral implantation of the 
placenta. The work of Rigby, published a few years later, but which 
contains no reference whatever to the observations of Roederer, is more 



376 HEMORRHAGE BEFORE DELIVERY. 

familiar to English writers, and certainly was the first to bring a correct 
knowledge of the subject under the notice of English obstetricians, what- 
ever may be the weight of the author's claims to originality. 

The Causes of placental presentation are but little understood. The 
fertilized ovum generally grafts itself, as is well known, upon some por- 
tion of the uterine mucous membrane, not far distant from the orifice of 
the Fallopian tube along which it has descended. It has been presumed 
that, as the connection between the chorion and the decidua is — prior to 
the development of the placenta — continuous over the whole of their con- 
tiguous surfaces, the actual site of the placenta may correspond to any 
point in the circumference of the ovum. The tumid and convoluted con- 
dition of the mucous membrane which obtains during menstruation, and 
for some days afterwards, is obviously well suited to the arrestment of 
the fertilized ovum, a body already endowed with independent vitality, 
and prone to adhere to any surface from which may be derived the 
pabulum on which the maintenance of that vitality must necessarily de- 
pend. Exceptional circumstances may, however, occur to permit of the 
descent and ultimate escape of a fertilized ovum ; and we may, there- 
fore, infer, that the ovum may, in any such case, be arrested near the 
cervix, and there go through the series of physiological changes upon 
which the formation of the embryo depends. The occurrence of extra- 
uterine pregnancy shows that contact with the membrane which is 
specially prepared for its reception is by no means essential to develop- 
ment of the ovum. There is nothing, therefore, extravagant in the 
assumption, that it may take root at a point of the uterine mucous mem- 
brane distant from the site which it ordinarily selects. It has even been 
held that the impregnation of the ovule may take place as low in the 
uterus as the cervix ; and, if it be so, this will no doubt serve to explain 
the phenomenon in question. But, even if we suppose the ovule to be 
impregnated before its arrival in the uterus — which is, as is believed, the 
usual course — there are many special circumstances which may account 
for its occasional gravitation towards the cervix before contracting ad- 
hesions. If, for example, its descent is, relatively to the menstrual 
period, later than usual, it may find the mucous membrane no longer 
tumefied and convoluted to the same extent as before ; and there can be 
no doubt that a smooth and flat surface would be more likely to permit 
of such gravitation than the other conditions of the membrane already re- 
ferred to as characteristic of a menstrual period. The probable result of 
such a case would be loss of the ovum ; but it is at least possible that it 
might yet be arrested in its descent, and graft itself upon a surface to 
which it is accidentally contiguous, as when it falls upon the peritoneum in 
abdominal pregnancy. All such speculations are, however, merely theo- 
retical ; for it must be confessed that, in so far as the etiology of placenta 
praevia is concerned, nothing definite is known. 

In the early months of pregnancy, there are no Symptoms which 
enable us to recognize the condition in question ; and, if hemorrhage 
should take place, it will probably be followed by abortion, in the course 
of which nothing would occur likely to direct our attention to the peculiar 
nature of the case. A sudden attack of hemorrhage, occurring at any 
period more advanced than that at which abortions generally take place. 



SYMPTOMS OF PLACENTA PRiEVTA. 377 

more profuse than usual, and for which no definite cause can be assigned, 
should always excite our suspicion, as it must necessarily demand our 
attention. Such hemorrhages, dependent upon placental presentation, 
usually occur in the course of the last three months of pregnancy ; and 
the nearer the pi-egnancy is to its natural termination, the more profuse 
is the discharge likely to be. If this symptom should be of earlier occur- 
rence than usual, the quantity w^ill probably be slight, and, under favor- 
able circumstances and judicious treatment, will speedily cease. After 
an uncertain interval, and often at what would have been the next men- 
strual period, the symptoms will, however, return with increased violence. 
Repeated hemorrhages of this kind, becoming progressively more alarm- 
ing, ultimately attract attention, and call for assistance. 

If at this stage we make an examination, we shall probably find that 
the OS and cervix are somewhat peculiar to the touch. This peculiarity 
consists in a doughy feeling, due to the unusual thickness of the cervix, 
which is necessarily permeated with large vessels for the placental circu- 
lation. And this feeling is further exaggerated by the presence of the 
placenta itself, between the finger and the presenting part, depriving the 
latter of its feeling of firmness and resistance. If the os is sufficiently 
dilated to permit the passage of the finger, the characteristic spongy 
tissue of the placenta may alone be felt ; or, if the case should be a 
lateral and not a central one, we may feel the edge of the placenta pro- 
jecting at one side of the os uteri, and possibly, the bag of membranes 
with the presenting part of the child at the other. If the flooding has 
been very severe, we may feel the detached surface of the placenta, 
which is lacerated and stringy to the touch ; and we may even discover, 
in some instances, where the separation has been extensive, a portion of 
the organ protruding into the os, or, through it, into the vagina. In pre- 
sentations of the breech or shoulder, which usually remain high in the 
pelvis, the detection of placenta pr^evia is more difficult, partly on this 
account, and partly because the placenta can less easily be felt than 
when it is between the finger and the resistant structures of the cranium. 

There is another class of cases, in which no symptoms whatever occur 
until the uterine contractions at the commencement of labor interrupt, 
for the first time, the continuity of the utero-placental vessels. Here 
the gush of blood is sometimes so fearful, as to cause immediate syncope, 
and in some cases the death of the woman before assistance can reach 
her. Hemorrhage before labor, therefore, has this advantage, — that it 
enables us to recognize the nature of the case at a period sufficiently 
early to adopt precautionary measures, with a view to the patient's 
safety. From the commencement of labor, the symptoms in the two 
varieties are identical. Each successive pain tends still further to the 
separation of the placenta from its cervical attachments, and consequently 
to increase the hemorrhage, so that, up to a certain stage, the more 
advanced the labor, the more imminent is the danger; and, if left to 
themselves, such cases almost necessarily prove fatal. It is here that 
the important practical distinction is drawn which enables us, even with- 
out a digital examination, to distinguish between Unavoidable and Acci- 
dental hemorrhage, and which led Rigby to adopt this useful classifica- 
tion. In the former, remissions may occur between the pains, but with 



378 HEMORRHAGE BEFORE DELIVERY. 

each contraction the flow of blood is increased; while, in the latter, the 
descent of the head bars the egress of the blood, the source of the dis- 
charge being higher in the uterus, as will be shown by-and-by, when we 
come to notice this special variety of flooding. 

It has been said that hemorrhage some time before labor is more 
likely to occur in cases of central than of lateral placenta prgevia ; and 
if we wore to draw an inference from the anatomical relation of the parts, 
we would be quite prepared to accept the correctness of this conclusion. 
Practical experience has, however, shown that we cannot depend on this, 
and that many cases of central implantation present no symptoms what- 
ever until these are developed by the occurrence of labor. It sometimes, 
though rarely, happens that the eff'ect of the uterine contractions is to 
separate the placenta either from its cervical attachments or from its 
entire uterine connection, so that the hemorrhage is comparatively 
trifling. In some of these instances, the detached placenta has been 
propelled into the vagina, and the foetus, then descending so as to press 
upon the orifices of the gaping vessels, has protected the woman, from 
that time onwards, from the further effects of alarmino; hemorrhao;e. 
This has suggested a mode of treatment of these cases which will be 
mentioned at the proper place, and which is not without strenuous advo- 
cates at the present day. Another rare termination of central placenta, 
of which cases have been recorded by Portal and others, is the birth of 
the child through the placenta. A case of this nature occurred in the 
practice of Mr. White, of lieathfield in Sussex, and is given by Rigby. 
The placenta was "centrally attached to the os uteri, Avhen, in conse- 
quence of two or three powerful pains, the head was forced through, 
tearing it quite across. The child was born dead, but the mother did 
well." Such terminations of placenta praevia are so rare, that not only 
do we place no reliance on them, but we do not even allow them to enter 
into our calculations in determining the mode of procedure which is to 
be adopted. It has even happened that in these cases children have 
been born alive ; but it is obvious that the life of the child must, almost 
of necessity, be sacrificed. This is a further reason for not trusting to 
nature in the circumstances now under consideration. 

More confidence may, at times, be placed in the efforts of nature, 
when the case is a partial one, and the placenta situated laterally with 
respect to the os. As the placenta may be implanted upon any part of 
the internal surface of the uterus, a considerable variety of cases of par- 
tial pjacenta previa may present themselves. In those cases in which 
the placenta spreads over a large portion of the cervix — and it has been 
observed that it is generally of greater superficial size than when it is 
developed at the fundus — the same treatment which is held to be appli- 
cable to central cases will be indicated. But, in the instances in which 
the bulk of the placenta is above the cervix, and a small portion only is 
implanted on that part, it is quite possible that, although labor may be 
ushered in by profuse flooding, the head may be permitted to descend, 
when it will act as a plug, and the natural powers will eff'ect a safe de- 
livery as regards both mother and child. And, a fortiori^ when the 
placenta can only be reached by the finger with some difficulty, this for- 
tunate issue O'f the case is the more likely to occur ; and, in fact, such 



TREATMENT OF PLACENTA PR.EVIA. 3T9 

cases should rather be looked upon as occupying a place intermediate 
between the " unavoidable" and " accidental" category. As is the case 
Avith regard to many other of the accidents of midwifery, there seems to 
be a proclivity to the recurrence of placenta praevia in those who have 
once been the subject of it ; and another and stranger fact has also been 
noticed by Rigby, Saxtorph, Naegele, and others, viz., that at certain 
periods this accident seems of more frequent occurrence than at others. 
The last named authority, in remarking on this, states " that in some 
years, placental presentation was so frequent that it seemed as if it were 
almost epidemic." 

Treatment. — The occurrence of hemorrhage in the last months of preg- 
nancy is of itself sufficient to warrant, and indeed to demand, an imme- 
diate vaginal examination. Should the existence of the symptoms already 
detailed reveal the presence of the placenta at the os, the future manage- 
ment of the case becomes at once a matter involving no little anxiety. It 
has already been remarked that the earlier the period of pregnancy at 
which flooding first takes place, the less is the immediate risk to the 
woman. The treatment of such cases differs but little, as Rigby well 
remarks, from that of an ordinary case of abortion. The indications, in 
fact, are the same, viz., to stop the discharge, and allay any disposition to 
uterine contraction. At the same time, no eftbrt must be spared to pre- 
vent, if it be practicable, further separation of the placenta. 

Nothing is, perhaps, of such importance as rest. The patient should 
be placed in a bed which is as hard as is compatible with comfort. With 
the view of keeping her cool, the temperature of the room must be 
attended to, and the bedclothes should be light. The bowels may be 
managed by gentle saline laxatives or enemata, and the patient should 
not be permitted to raise her shoulders ; nor, for a certain time after an 
attack, should she ever be allowed even to move in bed more than is 
absolutely necessary. The food at first should be of the lightest possible 
description, such as milk, arrowTOot, and the like, and should be given 
cool. Such restricted regimen cannot be persevered in for any length of 
time, so that we must soon introduce soups, fish, chicken, and more 
nourishing material generally into the dietary. The use of stimulants, 
except in so far as they may be necessary in the stage of de'pression, 
consequent on severe flooding, must be forbidden. But when the fre- 
quency and amount of the hemorrhage is at this stage great, the opinion 
is steadily gaining ground, that by bringing on premature labor we do 
what is best in the interests both of mother and child. ^ The probable 
result of hemorrhage, in placenta pr^evia prior to the seventh month is, 
as has been said, abortion. When gestation is further advanced, and the 
foetus has reached the period of viability, we endeavor to avert prema- 
ture delivery as long as is possible, in order to give the child the best 
possible chance. 

When hemorrhage and vaginal examination have revealed the nature 
of the case, at any time during the last three months of gestatioQ, we 
should inform the patient and her friends of the certainty of a recurrence 
of the flooding sooner or later. The number of the attacks, and the 

J See Dr. Greenhalgli's paper, Obstetrical Transactions, vol. vi. 



380 HEMOERHAGE BEFORE DELIVERY. 

period which may elapse between them, are points on which we dare not 
venture an opinion. In one case, the flow may be almost continuous, or 
have remissions only ; and, in another, there may be but one or two 
attacks, and these not seldom corresponding to menstrual periods. But 
the great peril, in every case, lies in this — that we can never foresee the 
moment when a torrent of blood may be poured out in such abundance, 
that the life of the woman is placed in instant jeopardy, and may be 
sacrificed before assistance can reach her. It is on this account that we 
should seriously consider the propriety of inducing premature labor, but 
if we resolve to delay, particular directions must be given, in order that 
no time be lost in summoning assistance. It is, moreover, of the highest 
possible importance that a skilful nurse should be in constant attendance, 
to whom the accoucheur may give instructions as to the method of 
plugging — the materials for which should be kept prepared and constantly 
at hand. 

The use of the vaginal plug or tampon, as applicable to the treatment 
of abortion, has already been described, and the proceeding in this case 
is precisely similar. The object of plugging, if practised before labor 
has commenced, is simply to prevent the flow of blood, without there 
being any ulterior object, as regards further operative procedure, in 
view. This is efiected partly by preventing the external flow, and partly 
by compressing the placenta between the plug and the presenting part of 
the child, and thus artificially damming up the source from which the 
blood has escaped. Although, as already remarked, the sponge is to be 
preferred on various grounds, it, and the coagulated blood which accumu- 
lates in its interstices, are so prone to decomposition, that it cannot well 
be retained beyond a few hours. In such cases, then, as it may seem 
advisable to maintain compression of the placenta for a longer period, it 
may be better to plug with slips of lint, tow, or some other similar sub- 
stance ; or, better still, by an india-rubber bag, which, after its introduc- 
tion, may be distended either with water or with air. Braun's Col- 
peury Titer is a contrivance of this nature. The plug must not, however, 
be used rashly in those cases in which the hemorrhage is as yet trifling, 
and in which, consequently, we are justified in temporizing, in the hope 
of preserving the child ; for experience, derived from the treatment of 
abortion cases, has clearly shown that the irritation of the plug is pretty 
sure, sooner or later, to excite uterine contraction. Where labor pains, 
however feeble, have already manifested themselves, or where the urgency 
of the symptoms precludes the hope of conducting the case to maturity, 
this particular action of the plug is rather an advantage, as, by stimu- 
lating the uterine fibres, the os is more rapidly and effectually dilated. 
Astringents, local and general, have been tried in every possible way in 
these cases, but it must be confessed that their action is not even in the 
slightest degree to be depended upon ; a result which will not excite 
wonder if the purely mechanical cause of the hemorrhage be kept in 
mind . 

When the flooding does not occur until labor has declared itself at the 
termination of pregnancy, or when, at any period, the hemorrhage is so 
profuse, and the general symptoms so urgent as to demand energetic 
action in the presence of a great emergency, our duty is to encourage 



TREATMENT OF PLACENTA PREVIA. 381 

contraction, and to complete delivery as soon as possible. With this 
object prominentlj in view, various modes of treatment have been recom- 
mended, to each of which it is necessary speciall}^ to advert. In a large 
proportion of the cases in which the os is as yet undilated to any extent, 
the only justifiable mode of procedure is to arrest the hemorrhage by 
plugging, and, at the same time, to favor uterine contraction by every 
means at our command. Plugging is, however, as will be observed, in 
all cases of placenta praevia, a mere temporary expedient, which is em- 
ployed with a view to ulterior proceedings. 

Evacuation of the liquor amnii by puncture of the membranes is a 
practice of great antiquity. The object of this in the present instance 
is to develop uterine energy, and to permit of compression of the pla- 
centa between the presenting part of the child and the uterine wall, so 
as to reduce the risk of hemorrhage. The cases to which this mode of 
procedure seems more particularly applicable, are those instances in which 
the placenta is situated more or less laterally, or, in other words, those 
in which the membranes can be reached before the os has become dilated, 
and without much risk of rupture of tissue. Its use, however, has not 
been confined to such cases, but has been recommended and practised by 
Deventer, Deleurye, Smellie, and, more recently, by others, who, in cases 
of central implantation, puncture the placenta, by a trocar or otherwise, 
with the result of arresting the hemorrhage. Rupture of the membranes 
is also applicable to all cases in which it is found expedient to induce 
premature labor, that is to say, if it can be effected with safety ; but, if 
not, of course other means must be adopted to rouse the uterus to activity. 
Dr. Barnes says " the puncture of the membranes is the first thing to be 
done in all cases of flooding sufficient to cause anxiety before labor. It 
is the most generally/ efficacious remedy, and it can aliuays he apjjUed.''^ 
The italics are his, indicating the emphasis with which he makes the 
statement, but in so far as our experience enables us to judge, we cannot 
endorse his assertion. And, moreover, we cannot but think that such a 
procedure as he describes of guiding a stylet or quill along the finger to 
the membranes must necessarily cause, for a time at least, an increase in 
the bleeding in central cases, as it certainly must a violent though partial 
separation of the placenta in a part of its circumference. The contrac- 
tion of the uterus may be further promoted by the action of ergot and 
the other oxytocics. Evacuation of the liquor amnii and the use of ergot 
are, it must be remembered, open to this objection, that by such treat- 
ment, the difficulty of the operation of turning is greatly increased, should 
that operation eventually be found necessary ; but if the operation for 
separation of the placenta is to be preferred, as is recommended by Dr. 
Barnes, this objection has no force. 

The operation of turning, Avhich will be more particularly described in 
another chapter, is that to which most modern authorities give the pre- 
ference in the treatment of cases of placental presentation. So long as 
this operation is looked forward to as one suitable to an individual case, 
not only must rupture of the membranes not be practised, but every 
means should be adopted which is likely to preserve their integrity. We 
shall not here anticipate the details of the ordinary operation of turning, 
but notice only those modifications of the operation which are rendered 



382 HEMORRHAGE BEFORE DELIVERY. 

necessary by the peculiar anatomical conditions of the case. Two 
methods have been suggested. That to which Dr. Rigby has lent the 
weight of his authority, consists in forcing the hand through the tissues 
of the placenta into the amnionic cavity, and then completing the opera- 
tion in the usual w^ay. 

This procedure has been abandoned as dangerous, and for the most 
part impracticable, in favor of the second method, the origin of which is 
generally attributed to Portal. The hand, in this case, is to be passed, 
not through, but by the side of the placenta, choosing, if it be possible 
to ascertain the fact, that side to which the placental adhesions are least 
extensive. It is very rare that the attachment is equal in extent all 
round ; and, of course, if there be any point of the circumference to 
w^hich the placenta is not adherent, that place should be selected for the 
passage of the hand. The usual precautions are to be adopted for pre- 
venting rupture of the membranes, and the hand is to be carried high 
into the uterus, between it and the membranes, until the situation of the 
feet is ascertained, when the fingers are thrust through them, a foot 
seized, and the operation completed in the usual way. During the course 
of this procedure — which is often easier of execution than under ordi- 
nary circumstances, owing to the relaxed state of the uterus, due to the 
hemorrhage — the arm of the operator acts as a plug, which effectually 
restrains external hemorrhaofe. When the foot is brouo-ht down into the 
vagina, the breech and trunk of the child forcibly compress the placental 
mass; and in this way one plug is replaced by another more efficient 
still. The action of the womb should be aided b}^ an external bandage, 
or by firm pressure, at this period, over the fundus, and a full dose of 
ergot may be administered, with the view still further of insuring efficient 
contraction. If the child is still alive, or if there is no evidence of its 
death (in which case Ave should act as if it were alive), delivery must be 
effected as rapidly as is consistent with the safety of the mother. With 
its birth, the critical period of danger will have passed, and the uterus 
will now contract firmly upon, and shortly expel, the mass of the pla- 
centa which is left behind. 

When the accoucheur is summoned at the commencement of labor, on 
account of the alarming flooding, he will probably find that the os is not 
sufficiently dilated to permit of the operation of turning with a reason- 
able prospect of safety. His first duty at this stage is to arrest the 
hemorrhage, until such time shall arrive as the condition of the parts 
may warrant him in proceeding to the operation. This can only be 
effected by the action of the plug, which is to be introduced in the man- 
ner above described. Or, what is more effectual still, strips of lint may 
be introduced, one after the other, through the speculum, as by this means 
the vagina can be more thoroughly packed. As the pressure of the 
plug is apt to interfere with the action of the bladder, it will be well to 
see that that viscus is empty before its introduction. A still more effect- 
ual method of plugging may at this stage be practised by means of the 
fiddle-shaped water bags, which we owe to the ingenuity of Dr. Barnes. 
A certain amount of dilatation is necessary for the successful application 
of these ; but if the os is of sufficient size to admit the point of the finger, 
it will then be practicable to pass a bag of small size. This may then 



TREATMENT OF PLACENTA PREVIA. 383 

be distended with water in the manner described by the inventor, and a 
firm elastic plug is thus formed, which serves the double purpose of pre- 
venting any escape of blood, and, at the same time, of mechanically dilating 
the OS by a safe and graduated method of pressure. The exchange of 
the small bag for one of larger size may, after an hour or so, be effected 
without much risk, if the operator is dexterous ; and, in this way, such 
dilatation of the os may be effected as will admit the passage of the 
fingers, and subsequently of the hand. But, whether we make use of 
the vaginal or cervical plug, the object is to dilate the os, with the view of 
subsequent operative procedure. 

It is to be remembered that extensive dilatation of the os is by no means 
essential to the successful performance of the operation of turning. The 
method of combined external and internal manipulation, which has already 
been referred to in the chapter on Transverse Presentations, and which 
will be more particularly described, affords a mode of procedure which 
is by no means difficult, and which is certainly safer to the mother. To 
effect this, the passage of one or two fingers through the os is all that is 
necessary ; and in so far as placenta pnievia is concerned, we are con- 
vinced that this method is peculiarly applicable, and will ultimately, in a 
great measure, displace the more familiar operation. 

"The conditions favorable for turning are," says Dr. Tyler Smith, "a 
dilated or dilatable state of the os uteri ; the retention of the liquor 
amnii, or a moderately relaxed state of the uterus ; a pelvis of average 
capacity ; the absence of dangerous exhaustion, or a temporary cessation 
of the hemorrhage." Nothing is of greater importance than that the 
operation should be attempted as early as possible, for there call be no 
doubt that the great mortality which attends these cases is due, in no 
small degree, to an injudicious expectant treatment, while the precious 
moments pass during which alone we can save the patient's life and that 
of her child. It may sometimes be necessary, when the case does not 
come under our observation until this more advanced and critical sta_2;e, 
to delay the operation, and to plug, until the woman is rallied by free 
stimulation from the state of incipient collapse into which she has fallen. 
In this, as in all other cases of prostration from hemorrhage, brandy given 
along with opium will effect the object in view as well perhaps as any 
other combination of stimulants which it is possible to prescribe. When, 
in such cases, the pulse and general appearance show that the woman has 
rallied, the operation may be commenced, and conducted with the special 
precautions which the circumstances demand. 

In cases of partial placenta prgevia, the operation of turning may not 
be required ; but if, in such, the hemorrhage is still alarming, after the 
head has descended so as to occupy a fully distended os, the labor may 
be completed by the application of the forceps. 

Artificial Extraction, and Artificial Separation of the Placenta — for it 
is proper to draw a distinction between the two — are operations which 
were suggested by what has occasionally been observed as a natural ter- 
mination of placenta prj^evia, viz., the birth of the placenta or its expul- 
sion into the vagina in advance of the child, ivitli cessation of the hemor- 
rhage. Imitating this, Drs. Wood, Radford, and Simpson, tried what 
had previously been done in a few cases, to separate and extract the 



384 HEMORRHAGE BEFORE DELIVERY. 

placenta, in the hope of speedily arresting the hemorrhage, and thus in- 
suring the safety of the mother. Simpson, with his usual indefatigable 
industry, collated a table, in which cases are given, showing the results 
to the mother in instances of turning. Contrasted with this is another 
series of cases, in which the placenta was expelled naturally or removed 
artificially before the birth of the child. The following represents, in a 
tabular form, the results of his elaborate statistics : — 

PlacentrPrlvia. Maternal Deaths. 

Turning .... 654 .. . 180, or 27.48 per cent. 
Extraction or Expulsion . 140 . . . 10, or 7.14 per cent. 

Such an issue as is represented by these figures is by no means, how- 
ever, a fair representation of the comparative risk attendant upon the 
two operations. On the contrary, by grouping together the cases in 
which natural expulsion had occurred with those in which the removal 
had been accomplished by operative interference,* the value of the com- 
parison is lost, as it must be evident that expulsion is less likely to be 
attended with a fatal result than those cases in which the parts are torn 
asunder by an operation which, however gently performed, implies a 
rupture of tissue by violence, involving the integrity of large vascular 
trunks. Although the figures are to this extent unreliable, it must be 
admitted that the cases upon which they are founded show quite clearly 
that separation of the placenta, whether natural or artificial, is accom- 
panied in a large proportion of cases with an abatement of the hemor- 
rhage, and of the more alarming symptoms. "Paradoxical as it may 
appear," says Simpson, " there are sufficient grounds and facts for be- 
lieving that, when the placenta is separated shghtly and partially, the 
chance of fatal hemorrhage to the mother is greater than whea the dis- 
union of the organs is entire and complete." 

It would serve no good purpose to follow the discussion to which 
Simpson's views as to the source of the hemorrhage in placenta praevia 
gave rise. These are essentially the same as were held by his prede- 
cessor, Dr. Hamilton, that^ the blood flowed not from the uterine, but 
from the placental orifices of the ruptured vessels, a point which, 
although of high physiological interest, must not divert our attention 
from the more important practical questions upon which it has but an 
indirect bearing. We must not omit to mention that the operation of 
extraction is, as regards the child, extremely unfavorable in its ultimate 
results — more so, certainly, than turning, if performed at the proper 
time. In this, also, Simpson's statistics are likely to mislead, if not 
carefully analyzed. Again grouping together indiscriminately cases of 
expulsion and extraction, he finds that, in 141 cases, the child was saved 
in 33, and, as the result as regards the child was not stated in a consider- 
able number of the remaining cases, it may be assumed that the actual 
number of children born alive was somewhat larger than is above stated. 
But here again the same source of fallacy comes into play, and, in point 
of fact, it is certain that the statistical results of spontaneous expulsion 
and artificial extraction should be carefully separated, otherwise the 
figures are very apt to encourage errors in practice. When the foetus is 
born by the efforts of nature, it has often been found to be expelled by 



TREATMENT OF PLACENTA PREVIA. 385 

the same pain which brings the placenta into the world, or at least fol- 
lows it within a very few^ minutes, a result extremely improbable in arti- 
ficial extraction. Dr. Simpson's own tables point conclusively to this 
fact, and in those cases in which the interval between the birth of the 
placenta and that of the child was more than ten minutes, he gives but 
one instance, occurring in the practice of Mr. Perfect, in which the child 
was born alive. Unless then it could be proved that a speedy delivery 
of the child could be depended upon after extraction of the placenta, that 
operation cannot be looked upon with favor, in so far at least as the 
interests of the child are concerned. 

But, should we even resolve upon the extraction of the placenta, the 
difficulties of the case do not terminate with the completion of that ope- 
ration. Thus we find that, of the entire number of 86 cases given by 
Simpson in his tables, delivery was effected by turning in 25 instances, 
and by other modes of operative procedure in 7, while in 9 the mode of 
delivery is not specified. This leaves 45 cases only in Avhich the de- 
livery was completed by the natural pains, and we may confidently con- 
clude that, if we could separate the cases of spontaneous expulsion, the 
issue of the operative cases would appear still more unfavorable. The 
inference which was drawn from Simpson's elaborate papers on this sub- 
ject, and the interpretation which indeed seemed to attach to them, was 
that the author wished to supersede the old operation of turning by that 
of artificial separation. "We might think it necessary to say something 
more in refutation of such a conclusion, were it not that the practice has 
never commanded general support, save under exceptional circumstances. 
x\nd, moreover, a careful re-perusal of Simpson's facts, arguments, and 
conclusions, seems very clearly to show that, wdiatever opinions may 
have been entertained by that distinguished accoucheur when he submit- 
ted his views to the Meclico-Chirurgical Society of Edinburgh in 1844, 
those were materially altered before his death. This appears even more 
clearly from the " Lecture Notes," by which the reprint of his selected 
obstetrical works edited by Dr. J. Watt Black is prefaced. 

We shall now refer to the mode of partial separation, which has of 
late years received a considerable amount of support. It is intimately 
associated with the name of Dr. Barnes, whose writings on the subject 
of placenta prcevia are among the most valuable of the many contribu- 
tions to obstetrical literature which we owe to him. The effect of the 
uterine contractions, and consequent dilatation of the os, is, as he has 
shown, to separate the placenta in concentric rings from below upwards, 
vessel after vessel being thus opened, and the hemorrhage proportionally 
increased. So soon as the separation has reached a certain height, the 
passage of the head may become possible, w-hile yet an amount of pla- 
centa sufficient to discharge the fanction of the organ may remain 
attached. Dr. Barnes maintains that the complete separation of the 
placenta as recommended by Simpson is impracticable. " In by far the 
greater number of cases," he says, ''the placenta extends higher than 
the meridian of the uterus, often reaching the fundus. The fingers are 
not long enough to reach even half way towards the further margin of 
the placenta. The diameter of the placenta is nine or ten inches ; the 
fingers will barely reach three inches. In the greater number of cases, 
25 



386 HEMORRHAGE BEFORE DELIVERY. 

therefore, in which the directions prescribed have been followed, the 
placenta has not been wholly detached, and the result, when successful, 
cannot be attributed to an operation which was not performed." As- 
suming this fact to be correct, and supposing, therefore, that to insure 
complete separation of the placenta, the whole hand must be passed into 
the uterus, he adds that this operation " is even more severe than turn- 
ing, which does not require the hand to be passed through the cervix." 
Here he obviously refers to the bi-polar method. There is, he infers, a 
zone or line around the lower part of the uterine cavity, above which 
spontaneous detachment and hemorrhage do not occur, and below which 
alone separation and unavoidable hemorrhage take place. 

On this hypothesis, then, the real period of danger is that during which 
the placenta is being separated from the cervical zone, and Dr. Barnes 
maintains with great confidence that this is the mode of action in many 
of the cases which have been narrated of spontaneous cessation of the 
flooding, the real facts being misinterpreted by the observer. In a case 
which recently occurred in the experience of the writer, the facts ob- 
served seemed strongly to corroborate the idea thus suggested, in regard 
to which he had previously been more than sceptical. A young woman, 
pregnant for the second time, had had several attacks of hemorrhage 
prior to the expiry of her pregnancy. With the first labor pains, 
another gush took place, and shortly after this, she was first seen and 
examined by him. He found the os sufficiently dilated to admit a single 
finger, and the placenta completely surrounding the orifice. During 
several successive pains it was observed that the quantity of blood for 
such a case was very trifling, and it was on that account resolved to 
leave the case for a time to nature, with the view of observing what 
course nature would adopt. Materials were prepared for plugging the 
moment this should seem to be necessary, and the case was anxiously 
watched. Soon afterwards pains came on of great violence, and in rapid 
succession, but there was only one short period of about a minute and a 
half, during which the hemorrhage was alarming, which suddenly ceased 
upon the rupture of the membranes. Upon an examination the head was 
now felt descending, and the woman was shortly afterwards safely de- 
livered of a living child. She made an excellent recovery. 

Whatever may be the method of treatment upon which it is resolved to 
act, the first difficulty generally is to effect the dilatation of the cervix 
with the least possible chance of hemorrhage. Dr. Barnes, believing 
that the tardy separation of the placenta from what he terms the 
'' orificial zone" of the uterus is the main cause of hemorrhage, recom- 
mends that, if rupture of the membranes, which is his first procedure, 
should fail, we ought at once to separate the whole of that part of the 
placenta which is adherent to the zone in question. The details which 
he gives are as follows : " Pass one or two fingers as far as they will go 
through the os uteri, the hand being passed into the vagina if necessary ; 
feeling the placenta, insinuate the finger between it and the uterine wall ; 
sweep the finger round in a circle, so as to separate the placenta as far 
as the finger can reach ; if you feel the edge of the placenta where the 
membranes begin, tear open the membranes freely, especially if these 
have" not been previously ruptured ; ascertain if you can what is the pre- 



TREATMENT OF PLACENTA PREVIA. 38T 

sentation of the child before withdrawing jour hand. Commonly some 
amount of retraction of the cervix takes place after this operation, and 
often the hemorrhage ceases. ... If uterine action return so as to 
drive down the head, it is pretty certain there will be no more hemor- 
rhage ; you may leave nature to expand the cervix, and to complete the 
delivery. The labor, freed from the placental complication, has become 
natural." Failing this, he then advocates the use of his hydrostatic 
dilators which at once expand the os, and arrest the bleeding. These 
bags, which we have had occasion repeatedly to use, and which we have 
ventured to suggest as applicable to the plugging and dilating of the os 
prior to turning, admirably serve the purpose of dilatation. After an 
hour or half an hour, the bag may be withdrawn, and if then the uterus 
remains inactive, with a continuance of the hemorrhage, or if the presen- 
tation turns out to be transverse, or otherwise abnormal, which is very 
common in placenta prasvia, the operation of turning is then to be re- 
sorted to by the bi-polar method. On a total of 69 cases treated by Dr. 
Barnes on this principle, the percentage of maternal deaths was only 
16-66. 

The various methods above described may be conveniently epitomized 
for practical purposes in the following propositions, in which it is at- 
tempted to give its proper value to each : — 

1. That the Evacuation of the Liquor Amnii is specially applicable 
to cases of lateral or partial placenta prgevia, and other cases in which 
the membranes can be easily reached ; and to cases in which the foetus is 
immature. 

2. That Ergot and other oxytocics may be administered, but it is to 
be remembered that both these and evacuation of the liquor amnii act so 
as to render the operation of turning more difficult. 

3. That Plugging is called for at various stages, and may be applied 
either in the vagina or in the os uteri. It is a mere temporary ex- 
pedient, and, in the case of turning, is an almost essential mode of pre- 
liminary treatment. 

4. That Extraction of the placenta, although, perhaps, not so imprac- 
ticable as Dr. Barnes supposes, is not to be resorted to unless the cir- 
cumstances be very exceptional, as when the operation of ■ turning is 
impossible, and that of separation has failed. 

5. That Separation of the placenta from the lower segment of the 
uterus is a much more justifiable procedure than complete extraction. It 
may be performed in all cases in which the condition of the parts or the 
state of the mother prohibit turning ; but the evidence in its favor is not 
as yet sufficiently clear to warrant us in abandoning the older operation 
of turning. That it arrests hemorrhage in a considerable proportion of 
cases is admitted, but until a more extended experience shall corroborate 
the conclusions of Dr. Barnes, it would be unwise to admit them as 
proved. Statistics in such a case are of little value, and this Dr. Barnes 
himself frankly admits. 

6. That the operation of Turning is that in which the great majority 
of experienced practitioners still place the greatest confidence. If the 
percentage of maternal deaths under this treatment is, as Simpson says, 
as high as 27*48, including all cases indiscriminately, we are certainly 



388 HEMORRHAGE BEFORE DELIVERY. 

bound to conclude that in those instances in which the patient is under 
treatment from the first, the results will be very much more favorable. 
It is not to be forgotten that the operation of turning is one which in- 
volves special risks, of which laceration of the os and cervix, terminating 
in uterine phlebitis, is not the least, and that, therefore, we must weigh 
well the responsibilities we undergo before we reject all other modes of 
procedure in favor of this operation as it is usually performed. The 
risk, however, has been greatly modified by the introduction of the bi- 
polar method of version. 

The so-called Accidental Hemorrhage differs in many essential par- 
ticulars from the unavoidable variety commonly called placenta prgevia. 
The designation is, of course, more an arbitrary than a philosophical 
one ; but as it is one generally intelligible to English readers, we shall 
not attempt to change it. In this case also, there is hemorrhage before 
delivery, but there is a most important clinical distinction to be drawn 
between the two. In the last three months of pregnancy the anatomical 
connection which subsists between the uterus and the placenta becomes 
more feeble, so that the one is more easily separated from the other. 
The wonder then is, not that the separation does in rare instances occur, 
but that it does not occur more frequently. In accidental hemorrhage, 
the placenta is attached to the uterus at its normal site. 

What the Causes are which, in such circumstances, lead to a separa- 
tion of the placenta are but little known or understood, but it has been 
observed that the separation rarely occurs in the young and robust ; 
while, in those who have borne many children, or in whom any cause 
may have led to constitutional feebleness, it is relatively of more frequent 
occurrence. If, in such cases, the flooding is to be looked upon as a 
symptom of constitutional depravity, that of itself renders the case a 
grave one ; but another source of hidden danger is that the hemorrhage 
is often concealed. Placental separation indeed occurs ; blood is in- 
sinuated between the membranes and the uterus ; obvious shock and 
even collapse are produced ; and yet no single drop of blood escapes 
externally, while laceration of the uterine wall has occurred from the 
over-distension of the cavity by a hemorrhage such as this. In other 
cases, again, the placenta has remained adherent at its margin, while an 
enormous quantity of blood has been effused between the uterine wall 
and the body of the placenta. It would appear that, in many cases, the 
separation of the placenta takes place in the centre and not at the margin, 
and that the blood makes its way towards the margin, and thence fre- 
quently beneath the membranes, until it makes its appearance externally. 
These are the cases which are generally described as accidental hemor- 
rhage. In some of them, the general symptoms are as severe as those 
which accompany a case of placenta prasvia, and, in others, are much 
more grave than the actual external flow would seem to account for. 
Sickness, pallor, dimness of vision, and fatal prostration may thus rapidly 
supervene in a case of this nature, before even the symptom of flooding 
has attracted any particular attention. 

Accidental hemorrhage may occur either before or during labor. The 
great diagnostic feature which, according to all authorities, from Rigby 
downwards, enables us to distinguish, during labor, between it and un- 



ACCIDENTAL HEMORRHAGE. 389 

avoidable hemorrhage, is that, in the latter, the effect of a pain is to in- 
crease the flooding, by still further separating the placenta ; in the 
accidental form of hemorrhage, the presenting part descends during a 
pain, and thus, by plugging the cervix, stops the external flow. 

Many writers seem to pass over these cases, as if they were of little 
importance, and were as nothing beside the more interesting physiologi- 
cal speculations which arise from a consideration of placenta praevia. 
In point of fact, however, they are extremely fatal to the child, and 
highly dangerous to the mother, so that their management involves, in 
some instances, no less anxiety than placenta prgevia itself. In so far 
as Treatment is concerned, the first step in accidental hemorrhage is, 
undoubtedly, to rupture the membranes, so as to give egress to the liquor 
amnii. This, by removing the strain on the uterine walls from within, 
has a well-known tendency to promote vigorous expulsive action on the 
part of that organ. It is, besides, the most efficient safeguard which it 
is possible to procure, for a pain not only plugs the os, by forcing down 
the foetus, but, what is more important, it compresses the placenta be- 
tween the uterus and the child, and, by the same action, mechanically 
closes the mouths of the vessels from which the blood has flowed. Fric- 
tion, ergot, and if there be much depression, stimulants, may also be 
used, with the object of encouraging uterine action in those cases in 
which it is feeble or absent. But these means may fail to excite efficient 
uterine action, and the expulsion of the uterine contents, upon which 
alone Ave can depend for the safety of the mother. Should this be the 
case, our next step, after indulging, in the absence of actual hemorrhage, 
in a reasonable amount of expectancy, should be to dilate the cervix 
gradually, by means of Barnes's bags, and to complete delivery by the 
operation of turning, in which the bi-polar method should always, if it be 
practicable, be preferred. The previous evacuation of the liquor amnii 
will, no doubt, render the manoeuvre of turning more difficult than it 
would otherwise have been ; but, on the other hand, as it is a failure of 
uterine action which calls for the latter operation, the atony of the ute- 
rine walls will generally compensate for the absence of those conditions 
which are usually held to be favorable to the performance of the opera- 
tion of turning. 

Under certain conditions, the plug is, in these cases also, indispensa- 
ble. Its use is indicated more particularly where the condition of the 
OS renders the membranes difficult of access, and where, after rupture of 
the membranes, hemorrhage still goes on. We must not forget, how- 
ever, that although we thus arrest external hemorrhage, an alarming and 
even fatal accumulation of blood may take place within the uterine 
cavity. This is best avoided by the use of ergot and a firm external 
bandage. 

The peril of the woman does not necessarily terminate, either in un- 
avoidable or accidental hemorrhage, with the birth of the child. In 
both, the placenta may be retained, and give rise to more trouble and 
renewed anxiety, or the uterine fibres may remain in such a paralyzed 
condition after the birth of the placenta that flooding may still go on 
from the patent orifices of the uterine vessels. In such an emergency it 
may, therefore, be necessary to apply some powerful styptic to the 



390 HEMORRHAGE AFTER DELIVERY. 

bleeding surface, with the view of arresting the post-partum hemorrhage, 
an object which, in the case of placenta prsevia, may be most effectually 
attained by swabbing the cervical zone with perchloride of iron, alum 
iron, or some other astringent ; but, in the case of the accidental variety, 
it may be necessary, in order to reach the bleeding surface, cautiously 
to inject the cavity of the uterus with the same powerful agents. Another 
source of anxiety in all these cases, even when the immediate dangers of 
the hemorrhage and operation have been surmounted, is the risk of 
puerperal pysemia and the allied affections, to the development of which 
such patients are peculiarly prone. 



CHAPTEE XXIY. 

HEMORKHAGE AFTER DELIVERY. 

Hemorrhage in the Third Stage of Labor. — Abnormal and Retained Placenta, and 
Irregular Uterine Contraction, as Causes of Flooding. — Post-partum Hem- 
orrhage. — Causes; General and Local. — Symptoms ; External and Internal 
Hemorrhage: Examination of the Abdominal Walls: Examination by the 
Vagina: General Symptoms: Symptoms ivhich indicate the approach of Death. 
— Treatment; Prevention: Treatment during the Hemorrhage: Pressure and 
Friction over the Uterine Region : Effects of Bandaging : Effect of Passing 
the Hand into the Uterine Cavity : Application of Cold : Astringents to Internal 
Surface: Galvanism : Ergot: Treatment by Plugging abandoned: Views in 
regard to Compression of the Abdominal Aorta : Application of the Perchloride 
of Iron and other Styptics: Objections to, and Arguments in favor of this Pro- 
cedure: Dr. Boftmes's Process. — Treatment directed to the General Condition 
of the Patient. — Effects of Rest and Position. — Reaction to be avoided after 
severe Flooding. — Secondary Post-partum Hemorrhage. — Transjusion: The 
^^ Mediate" and '■^Immediate" Processes: Dr. Aveling' s Apparatus : Injec- 
tion of Defbrinated Bloody and of Saline Solutions. 

Although hemorrhages which precede the expulsion of the placenta 
are not, properly speaking, post-partum, we shall, for convenience' sake, 
consider them here. The proper management of the placenta, with the 
object mainly of preventing hemorrhage, has already been explained in 
the chapter on the Management of Labor ; but there are some other im- 
portant matters which are still left for consideration, and as some of these 
have strong analogies with true post-partum hemorrhage, it has been 
thought better to include them in this section of our subject. Retention 
of the placenta, and consequent. hemorrhage, may be the result of mis- 
management ; but, independently of this, there are other causes, over 
which we have little or no control. If the circumstances attending the 
labor are in all respects normal, the placenta is probably separated en- 



ABNORMAL AND RETAINED PLACENTA. 391 

tirely, either during the birth of the child, or in the course of the dolor es 
cruenti which follow it. In a certain number of instances, however, the 
placenta is not separated in this manner ; owing, in one class of cases, 
to some anatomical peculiarity in the form of the placenta, in a second 
to atony, in a third to irregular contraction of the womb, and in a fourth 
to what has been described as morbid adhesion. 

Cases of abnormal placenta, in which the organ is divided, or has 
detached cotyledons, are of such rare occurrence that no practical impor- 
tance can be supposed to attach to them. A full account of these is 
given, with beautiful illustrations, in a recent work by Hyrtl.^ Should 
atony of the uterus be the cause, we must attempt without delay to excite 
uterine contraction by friction, cold applications, or ergot. In such a 
case, we have a double cause of hemorrhage in operation — an absence 
of the contractile force upon which the closure of the bleeding vessels 
depends, and a mechanical hindrance to that contraction in the presence 
of the placenta. Of irregular contractions of the uterus, tliat which is 
most frequently spoken of is " hour-glass" contraction, in which a spas- 
modic stricture of certain fibres of the uterus divides the organ into two 
cavities, within the upper of Avhich the placenta is imprisoned. This has 
been described as " encysted placenta," and is due in a great measure to 
atony or paralysis of the upper portion of the womb. True placental 
adhesion depends, again, on actual disease of the decidua or placenta, 
or, at least, on the presence of morbid products which are the result of 
antecedent disease. 

In all these cases, the treatment is the same, and consists in the speedy 
removal of the placental mass. If there is a loss of expulsive force, the 
hand should be cautiously passed into the uterine cavity, so as to grasp 
the whole placenta. A pause should, however, be made here until con- 
traction takes place, which is to be further aided by the pressure of the 
hand on the walls of the abdomen, so that, if possible, the placenta and 
the hand may be expelled together. If this is not done, the placenta 
may indeed be extracted, but, in such a case, flooding of the true post- 
partum variety can hardly fail to take place from the flaccid organ. If 
the so-called hour-glass contraction should be found to exist, the efforts 
of the operator must, in the first place, be directed to the stricture, which 
has to be overcome before the extraction of the placenta can be safely 
efl'ected. There is no doubt, however, that hour-glass contraction is of 
much less frequent occurrence than is generally supposed. It is a familiar 
expression, and is apt to be employed loosely, as representing all forms 
of irregular uterine contraction in which the extraction of the placenta 
is a matter of difficulty. When the uterus contracts irregularly, this ma- 
terially affects the process of separaiion of the placenta, besides mechani- 
cally hindering its extraction. The gradual insinuation of the hand into 
the womb, and the introduction of one or two fingers into the contracted 
portion, so as gradually, by gentle but sustained efforts, to overcome the 
morbid spasm, or other condition, which is indirectly the cause of the 
hemorrhage, is the treatment which is applicable to such a case. It re- 
quires no great force to wear out a spasm of this nature, and although 

^ Die Blutgefasse der menscliliclien Nachgeburt. Wien. 1870. 



392 HEMORRHAGE AFTER DELIVERY. 

at first it may be almost tetanic in its rigidity, it will gradually yield, 
and, by permitting the passage of the hand, admit of the easy removal 
of the placenta. When the cause of hemorrhage is the adhesion of a 
partially separated placenta, it is sometimes necessary to introduce the 
hand, and forcibly strip the organ from its uterine attachments. This 
peeling process, which must be conducted very slowly and steadily, will 
often occupy a considerable time ; but, fortunately, the cases in which 
the operation is required are of rare occurrence. It would appear that, 
in some of these instances at least, the uterine tissue, with which the 
placenta is in such intimate coimection, is morbidly soft and friable, so 
that the operator runs the double risk of leaving behind adherent por- 
tions of a placenta, the bulk of which has been removed, and of injuring 
the uterine walls, which are no longer, in their structure, such as to 
admit of even ordinary force. Do what we may, portions of placenta 
are sometimes left behind, which may require to be removed as the causes 
of subsequent hemorrhage, or which may afterwards be spontaneously 
discharged — a result which may, although very unjustly, be set down to 
the discredit of the accoucheur. Such retained masses have been re- 
moved, when unusually adherent, and polypoid in shape, by the wire rope 
dcraseur. 

In so far as the ordinary and normal condition of the placenta is con- 
cerned, the best safeguard against the hemorrhage in question is the 
proper management of the placenta during, and subsequent to, the birth 
of the child. This has already been described in another section of this 
work. 

True Post-partiim hemorrhage is an alarming and sometimes, in its 
effects, an appalling occurrence. When, in the course of labor, every- 
thing has passed as favorably as could be desired, the child is born alive, 
and the mother is apparently well, we naturally anticipate, as experience 
has taught us, a happy issue to the case. But the termination of labor, 
the real hour of trial to the mother, may be the beginning for her of a 
new and unforeseen peril. One of the essential physiological phenomena 
of labor is, as has been shown, the efficient contraction of the uterus 
during and after the birth of the child. This is nature's almost inva- 
riable safeguard. At times, unhappily, the uterine fibres which close 
the bloodvessels are relaxed, and blood pours forth Avith an impetuosity 
proportionate to the calibre and relaxation of the vessels, deluging the 
woman with blood, and reducing her in extreme cases to a condition of 
collapse which may be the immediate forerunner of death. So fearful is 
the torrent, in the worst cases, that, before we even have time to arrange 
our plan of treatment, our patient lies dead before us. The more expe- 
rience one has of the practice of midwifery, the more do we dread the 
occurrence of this form of hemorrhage, which we can seldom foresee, 
and Avhich is therefore all the more appalling, since we have seen no 
occasion to nerve ourselves and to prepare for an approaching emer- 
gency. 

Causes. — A certain number of cases are, no doubt, due to slovenly 
practice, a neglect of those details which should be matter of routine in 
every case. But, while such causes may generally be avoided by ordi- 
nary skill and attention, there are other instances where the causes upon 



CAUSES. 393 

•which the flooding depends are comparatively little, and sometimes not 
at all, within our control. One of the most important and, at the same 
time, most common cause of post-partum hemorrhage is uterine inertia. 
It may be that in these cases the uterine effort is simply exhausted, and 
complete atony is the immediate sequel of labor. Anything which may 
have tended to reduce the vital powers may lead to this. In women who 
have long suffered from wasting diseases, whose constitution may have 
been exhausted by many rapidly succeeding pregnancies, or in whom the 
vital energies have been in a measure sapped by a long continued or 
complicated labor, we see illustrations of those conditions, which are pre- 
disposing causes of hemorrhage after labor. No small proportion of the 
fatal cases seem to have occurred in women who were the subjects of the 
more advanced stage of Bright' s disease, or of any similar disease which 
exercises a deteriorating influence on the composition of the blood, in- 
creasing the watery at the expense of the corpuscular elements. When 
the placenta is of unusual size, or attached over a larger area than usual, 
the risk of hemorrhage is proportionally increased. 

It has been observed that, when the labor is unusually rapid, either 
from violent expulsive effort or deficient resistance, there is a tendency 
to post-partum flooding. It would appear, therefore, that a condition 
of safety is gradual emptying of the uterine cavity. In this way the 
fibres have time to contract to the enormous extent which is essential to 
the effectual closure of the vessels ; whereas, sudden contraction, although 
possibly efficient enough as regards delivery, cannot maintain itself, and 
is often followed by subsequent intermittent periods of relaxation, during 
which flooding is almost sure to occur. This, no doubt, is the reason 
why, after delivery by the forceps, and in some other obstetrical opera- 
tions, flooding is more frequently observed, — an excellent and sufficient 
warrant for the strict observance of the obstetric aphorism that we 
should empty the womb in operative cases as slowly as possible, and 
allow it to contract upon the child as it is being expelled. Sometimes, 
however, anxiety for the life of the child and other circumstances may 
lead us, for what may seem good reasons, to disregard this maxim ; but, 
in doing so, we should always admit into our calculations the fact that, 
in avoiding one danger, our pilotage may cause us to make shipwreck on 
another somewhat more remote. 

Fibroid growths connected with the uterus, and especially fibroid 
polypi are, if present, almost certain causes of hemorrhage after labor. 
It is well known that hemorrhage is one of the earliest and most constant 
symptoms of this affection in the unimpregnated state, and it is not there- 
fore to be wondered at that the proclivity to flooding should be more 
marked at the critical period which immediately succeeds delivery. This 
symptom may be caused in two ways, either by hemorrhage from the 
mucous surface of the tumor, or by the mechanical interference which it 
exercises in preventing the proper closure of the venous orifices in the 
wall of the uterus. 

Another affection may here be mentioned as an undoubted cause of 
post-partum hemorrhage, and which has, even by experienced observers, 
been mistaken for a fibroid polypus. We allude to inversion of the 
uterus. The symptoms of this, which will be more fully noticed in the 



39Jt HEMORRHAGE AFTER DELIVERY. 

following chapter, are indeed such as, under ordinary circumstances, 
could scarcely be mistaken. In the one, we have a tumor generally 
ovoid in shape, connected with a pedicle which we can trace up to the os 
or beyond it to its intra- uterine attachment ; in the other, we have also 
an ovoid tumor, but which ends abruptly by a more extensive attachment, 
within easy reach of the finger. In the former case, we find the distal 
extremity of the tumor encircled by a ring, formed by the os uteri more 
or less contracted ; in the latter, there is no such constriction. But this, 
be it remembered, applies only to the diagnosis of complete uterine in- 
version, which must pass, slowly or more rapidly, through various stages 
before it becomes complete, and at any one of these it may be arrested. 
In other words, inversion may be either partial or complete, and it is the 
former condition only which is likely to be mistaken for a polypus. In 
a case which, many years ago, came under our notice, there was a 
rounded tumor narrowing towards its upper part and tightly embraced 
by the os, and it was this condition which led to an erroneous diagnosis. 
In a precisely similar case, one of the most distinguished accoucheurs in 
Britain made a similar error, but fortunately discovered his mistake, just 
as he was about to remove the tumor by the dcraseur, by the pain which 
the patient complained of, and which he knew by experience was a most 
unusual symptom in manipulating polypi. Let us beware, therefore, of 
mistaking a partially inverted uterus for a polypus which is protruding 
from the uterine cavity. 

The Symptoms of post-partum hemorrhage are flooding, or the general 
symptoms to which it gives rise, or both of these combined. In by far 
the greater number of instances, the external discharge is at first, and 
throughout the whole course of the case, the most alarming, as it is the 
most palpable sign. It may immediately succeed the birth of the child, 
or may precede or follow the expulsion of the placenta. The quantity 
of the discharge is very variable, and upon this will depend, in a great 
measure, the opinion which we may form as to the gravity of the case. 
Generally, symptoms, more or less distinct, of uterine inertia will be 
manifested. The firm tumor which we are accustomed to feel behind the 
pubes loses its distinct outline, and becomes less perceptible to the touch ; 
or may disappear altogether, so that we can perceive nothing but soft- 
ness and fiaccidity. We may then feel parts, such as the projection of 
the last lumbar vertebra and the promontory of the sacrum, which w^e 
know to be separated from the fingers by the tissues of the womb. If 
the inertia or atony of the uterus is complete, this condition is persistent, 
and on introducing the hand into the cavity, which may generally be 
effected with ease, we find that the uterine walls are soft throughout, 
and, as Cazeaux graphically describes it, *' folded together like a piece of 
old linen." Such a condition, should it precede the separation of the 
placenta, may exist without hemorrhage ; but, if the third stage of labor 
has been completed, flooding is inevitable. In many of these cases, 
however, it will be to the observer a matter of wonder that the hemor- 
rhage should not be more profuse. Sometimes there are efforts on the 
part of nature to effect uterine contraction, when the hand, in the hypo- 
gastric region, may detect alternate relaxation and contraction of the 
organ, the latter periods being accompanied with the expulsion of such 



SYMPTOMS. 395 

blood as may have accumulated within the cavity during the former. This 
dis}30sition to rhythmical action on the part of the uterus is not at all un- 
common, nor is it to be looked upon with unnecessary apprehension, 
unless the actual flow of blood, or the general symptoms, are grave. 

The absence of alarming external hemorrhage is a negative symptom, 
which may divert the attention of the inexperienced from the true nature 
of the case. In some of these cases, bleeding may be going on internally 
to an extent which may rapidly place the woman in a position of extreme 
peril. The continuous absence of the uterine tumor, and the formation, 
subsequently, of an extensive and soft abdominal swelling, progressively 
increasing in size, will, along with the general symptoms which rapidly 
develop themselves, soon indicate what is going on. The conditions 
under which such symptoms may manifest themselves, are, first, a state 
of the uterus which admits of easy dilatation ; and, second, anything 
which mechanically impedes the external flow. Any displacement of 
the flaccid womb which may close the external orifice mechanically, is 
sufficient, in the first instance at least, to check the flow in the direction 
of the vagina. Subsequently, the occlusion of the orifice with a clot, 
which will form a more eff"ective plug if the os and cervix should be in 
any degree contracted, and at an earlier period, the pressure of the 
wholly or partially detached placenta, may in this w^ay form a barrier 
which, under ordinary circumstances, would speedily be swept away, but 
which, in the utterly flaccid and dilatable condition of the uterus, may be 
sufficient for the development of the phenomena in question. Sometimes, 
this process of distension is accompanied with great agony, which is not 
the result of attempted contraction of the organ, but of the morbid phe- 
nomenon of over-distension, an indication which is not unfrequently 
noticed in distension of the other hollow viscera. If the hand of the 
operator is now introduced into the cavity of the womb, he will recognize 
still more clearly the condition of matters, and he will find his fingers 
entangled in an enormous mass of clots, with which, and with fluid blood, 
the cavity is distended to an extent which may equal the size of the 
organ at the natural period of mature gestation. 

The general symptoms which indicate post-partum hemorrhage may 
exhibit themselves equally in external and internal hemorrhage. They 
are, unfortunately, fanuiliar to all experienced practitioners ; but, as 
symptomatic of the accidents we are now considering, they are, for ob- 
vious reasons, of greater importance in those instances in which the hem- 
orrhage is internal. In the worst cases, the symptoms are truly appalling, 
and in the course of a very few minutes the loss of blood may be so 
enormous as to plunge the woman, almost without warning, into a state 
of fatal syncope. In cases which, though less desperate, are scarcely 
less alarming, the woman may, with or without previous abdominal pain, 
and with or without external hemorrhage, experience a feeling of faint- 
ness associated with marked pallor. The vision becomes dim, and she 
calls out that she can no longer see ; vomiting frequently occurs ; and the 
extremities and general surface of the body become cold and bedewed 
with a clammy perspiration. The pulse becomes rapid, small, or imper- 
ceptible: and the paleness becomes so marked, so greatly exceeding all 
others, that Dr. Tyler Smith has called it "puerperal pallor." In some 



396 HEMORRHAGE AFTER DELIVERY. 

cases, however, the effect on the circulation is such as to produce, in the 
first instance, what is familiar to surgeons as the " hemorrhagic pulse," 
a symptom which is apt to mislead the inexperienced. This is a bound- 
ing and apparently full pulse ; but, if its character be more carefully 
tested, it is found to be remarkably compressible, and soon, with a con- 
tinuance of the flooding, merges into the more familiar condition of feeble- 
ness and imperceptibility. 

Such symptoms are manifestly indicative of a state of extreme peril, 
and, if prompt and skilful treatment be not speedily afforded, are too 
often the precursors of death, which may be preceded by dilatation of 
the pupil, hysterical paroxysms, or even by convulsions. It has fre- 
quently been observed that the amount of blood lost is not a safe crite- 
rion of the danger ; for, not only are we apt to be deceived in regard to 
the amount of internal hemorrhage, but there is the greatest possible 
variety in the symptoms which, in different women, attend a loss of a 
precisely similar amount ; and it may be added that it is not invariably 
the strong and robust who bear hemorrhage best, or recover most rapidly 
from its effects. In those cases in which hemorrhage after labor is due 
to a laceration more or less extensive of the os, or of any other portion 
of the parturient canal, the symptoms are rarely such as to excite alarm. 
The dangers to which such occurrences give rise are of a different nature, 
and do not manifest themselves till a later stage. 

Treatment. — There are, perhaps, few practical questions involving 
more anxious consideration than this. The young practitioner may find 
an illustration in the first case of midwifery which he is summoned to at- 
tend. He has no time for reference to books, no moment even during 
which he may appeal to his memory for facts which have escaped it ; and 
he must, therefore, be fully prepared by a thorough acquaintance with 
the subject, or he is unable to cope with so great an emergency. The 
principles on which all treatment depends, demand, then, his careful at- 
tention. 

It is perhaps scarcely possible to attach too great importance to the 
prevention of post-partum hemorrhage. Much will depend upon a proper 
management of the various stages of labor, retarding the action when 
this has a tendency to be precipitate, promoting it when the pains are 
feeble, and acting otherwise as has been recommended in the chapter on 
the management of labor. The importance of never leaving a woman 
until you are satisfied with the uterine contraction after delivery will, in 
view of the circumstances above stated, now become more manifest. We 
can never be sure of the case unless Ave are satisfied on this point. There 
are certain points here, however, which, if not understood, might result 
in the nimia diligentia of the tyro. First, it must ever be borne in 
mind that each case of labor is accompanied in its last stage with a cer- 
tain amount of hemorrhage, and this is not unfrequently considerable, 
without being accompanied, either then or subsequently, with any other 
symptom which should excite alarm. A second circumstance which may 
cause needless alarm is the gush of liquor amnii, mixed or colored with 
blood, w^hich immediately follows the birth ; and a third consists in what 
we very frequently observe, a certain amount of alternate contraction and 
relaxation which may seem to resemble, in some degree, the conditions 



TREATMENT. 397 

above described. An erroneous inference, drawn from these observa- 
tions, we have known to lead to treatment which was energetic enough 
certainly, but quite unnecessary, and, moreover, not attended with risk. 
Caution must, therefore, be exercised, lest, by giving undue prominence 
to one symptom without reference to the others, needless panic and im- 
proper interference be the result. 

There are cases in which the history of previous labors, no less than 
the circumstances attendant on that which is going on, indicate at least 
the probability of a similar result, and in such it is always proper to- 
wards the end of the second stage, or at least before the extraction of the 
placenta, to administer ergot, with the object of insuring efficient con- 
traction ; and the same agent may be used in all cases in Avhich, after 
the expulsion of the placenta, there is a tendency to atony. Moreover, 
we would do wrong, knowing what we do of the effect produced upon the 
uterus by excitation of the nipples, were we to omit to have the child 
placed early to the breast. These means, along with the application of 
the abdominal bandage, and the otlier details which have previously been 
fully described, constitute Avhat is called preventive treatment. ' 

The course of procedure, to be adopted in actual presence of the 
emergency, is the real question w^iich may task our knowledge, our 
nerve, and our ingenuity to the utmost. The object which, before all 
others, we have in view, is to promote uterine contraction, and if we fail 
in this, we fail utterly. Of the various methods which we have at com- 
mand, that which is invariably first employed is manual pressure 
exercised upon the fundus of the uterus, and also upon its lateral walls, 
by attempting to grasp the whole organ. In doing this, we do not so 
much depend upon the effect of such mere mechanical compression, as 
upon the more indirect action whereby the uterus is excited to contract, 
a result which is further encouraged by circular friction exercised over 
the fundus of the organ. The effect of the abdominal bandage at this 
moment certainly is to aid contractile effort, by affording a substitute for 
the support which has been lost by the inevitable relaxation of the ab- 
dominal walls. The bandage is, however, no advantage, but the con- 
trary, when it prevents us from ascertaining and, when necessary, con- 
tinually watching the condition of the uterus and its relation to the 
abdominal walls. It is best to have it loosely attached, so as to admit of 
easy removal and re-application, and by placing one or more folded 
towels over the hypogastric region, the compression of the uterus is kept 
up continuously, and is not temporary or intermittent as that of the hand 
necessarily must be. Should this not be immediately followed by satis- 
factory uterine contraction, the hand should be passed into the vagina, 
so as to ascertain the condition of the uterus more exactly. Sometimes 
the irritation of the cervix which is thus caused, results, with the aid of 
the external hand, in the action so much desired ; but should the organ 
remain in a state of complete atony, the hand must be passed into the 
cavity, in order still further to stimulate contraction by contact with its 
internal surface. When the hand is so passed it should be moved about 
within the womb, so as to collect, as far as possible, within the palm, the 
clots which occupy the cavity. This movement will generally suffice to 
awaken uterine action ; but in every case we must be careful not to re- 



398 HEMORRHAGE AFTER DELIVERY. 

move the hand except during sensible contraction, when the uterus may- 
be permitted, as it were, to expel the hand, and with it the retained 
clots. 

The reflex effect of cold in producing uterine action is often well 
marked. This may be applied either to the abdominal or thoracic walls, 
to the vulva, or by injection to the rectum or vagina. It has often been 
observed, even in cases in which the action of this powerful agent was 
at first marked, that its continuous action is not to be depended on. 
However effectual, therefore, it may seem in the first instance, when 
applied suddenly by the douche or otherwise, it should not be continued 
too long, otherwise an effect the reverse of beneficial is apt to be pro- 
duced. The injection of the uterine cavity with iced water, or the 
application to the inner uterine surface of a piece of solid ice is, under 
circumstances of emergency, quite justifiable, and has often proved effi- 
cacious. The alternated action of heat and cold has been found more 
useful than sustained cold, and in some cases in which cold has failed, 
the injection of water at 110° Fahrenheit will sometimes produce the 
most favorable results. M. Evrat recommended the use of a peeled 
lemon, which he introduced into the cavity of the uterus and then 
squeezed, so as to project the acid juice upon the bleeding surface. A 
sponge wrung out of vinegar and other astringents have, in the same 
way and for the same purpose, been introduced, and the effect of such 
applications has not unfrequently been to rouse the uterus from its dormant 
condition. Galvanism has also been employed with good effect, and may 
always, if immediately available, be tried. In cases in which clots again 
form within the cavity of the womb, these should be removed, as by pre- 
senting a mechanical impediment to feeble contraction they encourage a 
continuance of the flooding ; and, as before stated, it is well to allow the 
hand and the clots to be simultaneously expelled by uterine action, 
should it be possible to arouse the organ to such an effort. 

In the worst cases, little dependence can be placed in the use of ergot, 
for before sufficient time has elapsed to admit of the physiological action 
of the drug, the patient may be dead. If employed, it is to be given in 
full doses, and at as short intervals as is possible. The stomach will, how- 
ever, often reject it, as indeed, when the patient is in a state of extreme 
collapse, it will reject anything solid or fluid which may be swallowed. 
This is not to be looked upon as in itself an unfavorable occurrence, as 
it has often been observed that violent retching is attended Avith uterine 
action, so much so indeed that some practitioners have actually prescribed 
ipecacuanha with the view of obtaining its emetic effect. Turpentine in 
half ounce doses has been strongly recommended, and its effects seem in 
many cases to have been most satisfactory. Plugging, as a method of 
treatment, is of ancient origin, and has been advocated in modern times 
by Leroux and others who adopted his opinions ; but, as it has proved 
inefficacious, it has been abandoned. The mode of action must obviously 
have been, whether the plug was applied in the vagina or within the womb, 
to convert external into internal hemorrhage, and in no sense, therefore, 
to benefit the patient. The last attempts of this nature which have been 
made would seem to have consisted in the introduction within the uterus 
of Gariel's air pessary, which was then distended in the hope of com- 



COMPRESSION OF THE AORTA. 399 

pressing the bleeding vessels, an effect which a more correct knowledge 
of the condition of the uterus will not permit us to count upon. 

The flaccid condition of the abdominal walls which immediately suc- 
ceeds delivery, enables us, without difliculty, to press upon, and more or 
less effectually arrest the flow of blood through, the aorta. In desperate 
cases, therefore, the compression of this great vessel has been practised, 
in order to arrest the torrent which continues to pour from the uterine 
vessels ; but the practice has by some been violently opposed on theo- 
retical grounds. Baudelocque maintained continuous pressure upon the 
aorta for several hours, and imagined that in this way there was at least 
a gain of time, during which ergot and other agents might act, and the 
strength of the woman be restored. The most weighty objection to the 
practice is obvious, in the fact that the source of the hemorrhage is not 
so much in the curling arteries as in the venous sinuses, so that aortic 
compression cannot be supposed to exercise a very decided effect. But 
there is, moreover, another objection which has been urged — viz., that it 
is scarcely possible to compress the aorta, without at the same time sub- 
jecting the vena cava to more or less pressure, so that directions have 
been given whereby the pressure is to be directed to the left side of the 
vertebrae, in order to avoid the vena cava. Cazeaux believes that the 
result of such compression of the vena cava should be looked upon as 
rather a favorable condition than otherwise ; and we are certainly in- 
clined to agree with him in thinking that, in the worst cases, the volume 
of blood can only be accounted for by supposing that it proceeds, by re- 
gurgitation, from the great venous trunks. Two methods of compression 
of the aorta have been recommended ; in the one, the vessel is compressed 
through the abdominal walls, and in the other the hand is passed into the 
uterus, and the vessel closed — as is assumed, more effectually — by pres- 
sure through the posterior uterine wall. AVhile it must be confessed that 
the results of this procedure have not been such as to encourage us to 
look upon it with anything like confidence, there still seems to be in it a 
ray of hope, to which, when all else may have failed us, we cannot close 
our eyes. By all means, therefore, let aortic compression be tried. 
There is certainly no evidence upon which we can rely, that the practice 
has ever been productive of harm, while many believe that it, at least, 
arrests temporarily the rapid collapse which is so characteristic of a con- 
siderable proportion of such cases. 

The application, not of astringents merely, but of powerful styptics, 
to the inner surface of the uterus, is a mode of treatment which has, 
during the last few years, attracted considerable attention in this country. 
The procedure is not a new one, and even as regards the styptic salts of 
iron, which are undoubtedly the best, they were originally used by D'Outre- 
pont, and also by Kiwisch, who, upwards of thirty years ago, strongly 
supported this method of treatment. The action of such powerful agents 
is looked upon by most practitioners with considerable apprehension, and 
that it is so, is not, perhaps, to be wondered at. Nothing is more un- 
justifiable than such a procedure, unless other means have been tried, and 
have failed to arrest the flow of blood ; but in the presence of a great 
danger and instant peril, the objections to the application of styptics have 
less force. We do not wish in any way to undervalue these objections ; 



400 HEMORRHAGE AFTER DELIVERY. 

but even admitting their validity, and viewing the operation in the light 
of a desperate remedy, the facts which are given by Kiwisch, and re- 
cently in this country, by Dr. Barnes, are such as to afford us much encour- 
agement, and warrant us, in cases of emergency, in availing ourselves of 
this method of treatment. 

It is proper, however, to notice here the dangers which may arise 
from the injection of perchloride of iron, which have been very fairly 
put by Dr. Barnes, the chief supporter in this country of the bold em- 
ployment of the more powerful styptics. The perchloride produces 
immediate coagulation of any blood with which it may be brought in 
contact, but the danger to be dreaded is, that such coagulation might 
extend further ; and, should coagula be carried to the centre of circula- 
tion, death would be the probable, if not the inevitable result. Imme- 
diate death has followed the injection of even a few minims into a nsevus, 
and in one such case which is quoted by Dr. Barnes, "examination 
showed that the point of the syringe had penetrated the transverse facial 
vein, and that the blood in the right cavity of the heart had been imme- 
diately coagulated." Several cases have occurred on the Continent, 
and at least one in England, in which an injection of the perchloride into 
the womb has resulted in death by peritonitis, caused by the passage of 
a portion of the injection through the Fallopian tube. It is not to be 
forgotten that a similar result has followed the injection of fluids which 
are comparatively innocuous ; but the possibility of such a result must, 
under no circumstances, be lost sight of. Forcible injection of the ute- 
rine cavity should never be attempted. Were it possible thoroughly to 
sponge the inner surface of the uterus in an efficient manner, this, no 
doubt would be preferable ; but, as it would be all but impossible thus 
to bring the styptic solution into actual contact with the bleeding surface, 
some other means must be adopted. We are ignorant, it must be remem- 
bered, of the extent, or even the exact site of the surface from which the 
blood flows ; and, moreover, the cavity is so occupied with fluid, and 
clotted blood, that we could not hope, by any mere process of sponging 
the actual surface of the mucous membrane, effectually to reach it. Dr. 
Barnes says, however, that the conditions inseparable from a recent de- 
livery, are a relaxed and patent condition of the os, which would readily 
admit of an escape into the vagina of any fluid injected in excess, so that 
the conditions are, in all respects, different from what has obtained in 
most of the fatal instances recorded where injection has been practised 
in an unimpregnated, and sometimes in a displaced, uterus. 

The following is the course recommended by Dr. Barnes : " You have 
the Higginson's syringe adapted with an uterine tube eight or nine 
inches long. Into a deep basin or shallow jug, pour a mixture of four 
ounces of the Liquor Ferri Perchloridi Fortior of the British Pharmaco- 
poeia, and twelve ounces of water. The suction tube of the syringe 
should reach to the bottom of the vessel. Pump through the delivery 
tube two or three times to expel air, and insure the filling of the appa- 
ratus with the fluid before passing the uterine tube into the uterus. This, 
guided by the fingers of the left hand in the os uteri, should be passed 
up to the fundus. The injection should then be effected slowly and 
steadily, when you Avill find the fluid come back into the vagina mixed 



USE OF STYPTICS. 401 

with coagula, caused by the action of the fluid. The haemostatic effect 
of the iron is produced in three ways : first, there is its direct action in 
coagulating the blood in the mouths of the vessels ; secondly, it acts as a 
powerful astringent on the inner membrane of the uterus, strongly corru 
gating the surface, and thus constringing the mouths of the vessels ; 
thirdly, it often provokes some amount of contractile action of the muscu- 
lar wall." All facts hitherto recorded seem to show, that we have in 
this an almost certain means of arresting uterine hemorrhage, and Dr. 
Barnes insists that we should not defer its application too long, but resort 
to it without hesitation so soon as the ordinary means have received a 
fair trial. To wait until the vital powers are all but exhausted is cer- 
tainly not giving the measure fair play ; but we apprehend we would 
only be justified in having recourse to such a procedure after the ineffi- 
cacy of the other means has been thoroughly proved. 

[While there is no reason to doubt the efficiency of intra-uterine injec- 
tions of the salts of iron in post-partum hemorrhage, and while the editor 
has seen the undiluted solution of the subsulphate used without any bad 
results, it cannot be denied that death has followed as a consequence of 
this method of treatment. For this reason Professor J. D. Trask, of 
Astoria, Long Island, in a paper published in the American Journal of 
Obstetrics for February, 1875, proposes to resort to intra-uterine injec- 
tions of iodine, a measure originally proposed by M. Dupierris, of Ha- 
vana, Cuba. M. Dupierris used half an ounce of the tincture of iodine 
diluted with an ounce of water. The condition of one of the patients 
whose history is related was certainly desperate, but the injection ar- 
rested the hemorrhage, and she finally recovered. — P.] 

In the course of any treatment which may be adopted, the general 
condition of the patient must of course receive earnest and continuous 
attention. The tendency to syncope must be combated by free stimula- 
tion by brandy, or by brandy and opium in combination, upon which, we 
confess, we place even more reliance. The frequently repeated objec- 
tion to opium in such cases is, that it is an agent which arrests uterine 
action, and therefore should be avoided when our object is exactly the 
contrary of this ; but experience has shown that a drachm of laudanum, 
or forty minims of Battley's solution, combined with brandy or some 
other stimulant, will always be found, if it acts at all, to act in a benefi- 
cial manner by rallying the patient from collapse, and either thus indi- 
rectly, or, it may be, by a more direct action, exciting the uterus to 
contract. The patient should always be placed upon her back with the 
pelvis high and the head low. The object of this is, not only to take 
advantage as far as is possible of the law of gravity as a haemostatic, but 
also to prevent that lateral bagging which is apt to take place in a re- 
laxed uterus in the ordinary obstetrical position. Perfect rest and the 
recumbent posture are essential, not only at the time of the hemorrhage, 
but for a considerable period thereafter. All danger does not cease 
with the arrestment of hemorrhage, or even with uterine contraction; 
so that all these measures must be insisted upon as safeguards against 
the recurrence of the peril with which the patient has been menaced. If 
it be a rule never to leave a patient, even after natural labor, without 
satisfying ourselves of the state of the uterus, how much more important 
26 



402 HEMORRHAGE AFTER DELIVERY. 

must it be to watch the case in which hemorrhage has already caused us 
anxiety, and in which there is always a tendency to its return. Flooding 
may, in some instances, only become alarming when some time has elapsed 
after delivery ; but in most cases it will be found to be due to the reten- 
tion within the womb of a portion of the placenta or membranes, or of 
clots which have prevented the thorough closure of the cavity. 

The tendency to syncope should, in all cases, be combated as far as is 
in our power ; nor, in a condition of great depression, should the patient 
be permitted to yield to the drowsiness which overtakes her, as this may 
prove as fatal as that which is the result of exposure to intense cold. 
The period of convalescence after severe hemorrhage is one which may 
require great care and management. There is, above all, a tendency to 
reaction, which may manifest itself in the form of prsecordial oppression, 
severe headache, and throbbing of the carotids, which injudicious treat- 
ment, either by alcoholic stimulants or improper articles of diet, may 
increase to symptoms more serious still. The bulk of the blood which 
has been removed must be replaced gradually, and with caution ; and 
although the tolerance of stimulants is, during the hemorrhage and in 
presence of the symptoms of collapse, sometimes truly marvellous — when 
brandy seems to produce no more effect on the brain than as much pure 
water — it is quite otherwise when the immediate danger has passed and 
the patient begins to rally. When the symptoms which indicate reaction 
subside, it may be necessary to persevere, by means of generous diet, 
old wine, and tonics, for many weeks, or even months, before the system 
recovers from the fearful state of depression into which it has been 
thrown. 

It sometimes happens that hemorrhage comes on a considerable time 
after labor has terminated in an apparently favorable delivery. This is 
what has been described by M'Clintock,^ under the name of Secondary 
Hemorrhage, as '^ commencing after a patient has been six hours delivered, 
and within a month from this event." Although this variety occasionally 
springs from constitutional causes, it is more frequently associated with 
retention of a portion of placenta, or clots in the cavity of the womb. 
In other cases, the flooding has been found to be due to a polypus or even 
to inversion of the uterus, while among the rarer causes may be men- 
tioned the bursting of a uterine haematocele and retroflexion. In some 
of these cases, a careful examination will at once reveal the cause of the 
hemorrhage, and suggest the appropriate treatment ; but, in others, we 
may only be able to conjecture that the cause is to be discovered within 
the uterus. In the latter case it is often necessary to dilate the os, by 
tents or otherwise, so as to admit of a thorough exploration of the ute- 
rine cavity, with a view to the removal of the cause or it may be the 
application of styptic agents. If a portion of the membranes or of the 
placenta has been retained, and the case otherwise left to nature, the 
woman will probably be subject for a time to repeated and possibly dan- 
gerous floodings, until the retained parts are gradually decomposed, and 
discharged, though at the risk of septicasmia, in the form of a fetid 
lochia. 

1 Clinical Memoirs on Diseases of Woman. Dublin, 1863. 



TRANSFUSION. 



403 



There are cases in which the arrest of hemorrhage, although complete, 
seems to have come too late, the recuperative forces of nature having 
been too seriously compromised. There remains in these cases a state of 
utter prostration in which there seems to be no tendency to rally, an 
irritable stomach, a continued tendency to syncope, and an apparent 
arrestment even of the function of assimilation. Such a state of matters 




Dr. AyeliDg's Apparatus for Transfusion. 

can only terminate in one way, unless we can induce a rally, and the 
feeble hold which the patient has on life is gradually, but too surely re- 
laxed. These are the cases in which, however desperate the circum- 
stances, the operation of transfusion has succeeded, and we hope may 
often again succeed in rescuing the woman from the very jaws of death. 
This operation may be performed in various ways. The simplest process 
is that of immediate transfusion by some such simple apparatus as has 
been recommended by Dr. Aveling.^ This is described as consisting " of 
two small silver tubes, to enter the vessels, and of an India-rubber tube 
by which they are united, and which has in its centre an elastic recep- 
tacle, holding about two drachms. It is without valves, and is simply a 
continuous pipe with an expanded portion in the middle. By its means, 
the vessels are, as it were, extended from one to the other, and a supple- 
mentary heart is added to regulate the circulation." Air is got rid of 
by first pumping water or a saline solution through it, and then seeing 
that it is quite full of blood before the tube is inserted into the recipient 
vein. 

In what has been called, in contradistinction from the other, the medi- 
ate process, the blood is first received in a vessel, in which it is kept at 
the proper temperature, and it is thence injected by means of a syringe, 
different varieties of which have been devised by Drs. Little, Richardson, 
and Graily Hewitt. In addition to the difficulty which attends the ex- 
clusion of air, another and no less formidable one consists in the ten- 
dency of the blood to rapid coagulation. It has been attempted, with 
the view of obviating the latter, to inject the defibrinated blood only, the 
blood being received in an open vessel, rapidly stirred so as to promote 

1 Obstetrical Transactions, Tol. vi. p. 133. 1865. 



404 HEMORRHAGE AFTER DELIVERY. 

coagulation, and then filtered. In a considerable number of cases, this 
process has been attended with successful results, sufficient at least to 
prove that the presence of fibrine is not essential ; but the preponderance 
of professional opinion is decidedly in favor of the "immediate" process. 
It has been proposed by Dr. Richardson, as a corollary to certain well 
known experiments and conclusions of his, to prevent coagulation by the 
mixture with the pure blood of ammonia in the proportion of three drops 
to each ounce ; and, with the same object in view, Dr. Braxton Hicks 
has used the phosphate of soda. Some, arguing from the effects which 
have been known to follow the injection of a simple saline solution into 
the blood in the collapse of cholera, have advocated a similar mode 
of procedure in hemorrhagic collapse. The quantity to be introduced 
is much greater than when blood is used, and the following is the 
formula for the preparation of a solution which has been used by Dr. 
Little: — 

Chloride of Sodium . . . . . . . 60 grains. 

Chloride of Potassium 6 " 

Phosphate of Soda 3 " 

Carbonate of Soda . . . . . . . 20 " 

Distilled Water 20 ounces. 

Perhaps the simple apparatus and process of Dr. Aveling is the best 
for ordinary purposes which has hitherto been devised, and from its 
simplicity of construction, it may be used by any one possessed of 
moderate dexterity. The operation has not been confined to cases of 
post-partum hemorrhage, but has also been employed in placenta praevia, 
when the patient was too prostrated to survive delivery unless previously 
rallied. The successful performance of transfusion may, although fol- 
lowed by a rally, be again succeeded by renewed flagging of the circu- 
lation, and a recurrence of the original symptoms. In this case it would 
be quite proper to repeat the injection. Professional attention has of 
late years been so thoroughly awakened to the importance of this pro- 
cedure, that there exists in the minds of many experienced practitioners 
a strong hope, and some confidence, that obstetric mortality may in this 
way be in some measure reduced. 



INVERSION OF THE WOMB 



405 



CHAPTEE XXy. 



INVERSION OF THE UTERUS. 



Varieties of Inversion: Three Stages of the Ordinary Variety. — Inversion of the 
Unimpregnated Uterus. — Inversion usually occurs during the Third Stage of 
Labor. — Causes: Bragging upon the Cord: Shortness of the Cord: Irregular 
Contraction of the Uterus. — Connection of this Accident with Hour-Glass Con- 
traction. — Effects of Paralysis of the Fundus. — Mechanism of the Displace- 
ment. — Symptoms: Peculiar Violence of the Shock: Hemorrhage: Absence of 
Tumor in Hypogastrium. — To be distinguished from a Fibrous Polypus. — 
Sensibility and Occasional Contractility of the Tumor. — Modes of proving the 
Absence of the Uterus from its Normal Situation. — Recurrence of Hemor- 
rhage in Chronic Inversion. — Treatment: Ordinary Method of Replacement: 
Management of the Placenta if still Adherent : Management of more Difficult 
Cases: Compression of Tumor: DepauV s Instrument. — Chronic Inversion: 
Montgomery's Method of Ptcposition: Constriction of the Os must be Over- 
come: Effects of Sustained Elastic Pressure: Division of the Stricture: Re- 
moval by the Ecraseur. 

Inversion of the Womb has already been referred to in the preceding 
chapter as one of the causes of hemorrhage after delivery. Although 
the accident is by no means of frequent occurrence, it is not to be sup- 
posed that, on that account, it is to be treated as one of minor consequence. 
On the contrary, it involves so many practical 
questions, and is, moreover, a subject in regard 
to which so much misapprehension has existed, 
and still exists, that it is necessary to devote 
some space to its consideration. 

The idea essentially involved in the term 
"Inversion of the Womb" is an abnormal con- 
dition of that organ, in which, in extreme cases, 
the whole organ is turned inside-out. As has 
already been remarked, such a displacement 
must, in becoming complete, pass through a 
variety of stages ; and as, at any one of these 
stages, the inversion may be arrested, it is pos- 
sible to imagine an almost infinite number of 
varieties of inversion. We shall, however, only 
mention four. Of these, the first is not gene- 
rally described, but is said by Dr. Matthews 
Duncan to be " not rarely observed after de- 
livery." The condition of the parts is as shown in this diagram (Fig. 
185), and consists, therefore, in an inversion of the inferior segment of 



Fiij. 135. 




Partial Inversion. (After 
Matthews Duncan.) 



406 



INVERSION OF THE UTERUS. 



the uterus only. This variety, although, probably, not uncommon, and 
possibly sometimes the forerunner of complete inversion, is of no great 
practical importance, and will probably rectify itself without assistance. 
It is otherwise with the three varieties which are figured diagrammatically 
in Figs. 136, 137, 138. All these are, as will be observed at a glance, 
merely stages in the progress of the same accident, which is the true 
Inversio Uteri of authors, and which differs from the other and less im- 
portant variety, in commencing at the fundus. The ordinary course is — 
first, one of Depression of the Fundus (Fig. 136) ; second, one of Par- 
tial (Fig. 137) ; and, third, one of Complete Inversion (Fig. 138). In 



Fig. 136. 



Fiff. 137. 



Fig. 138. 





Successive Stages of Inversio Uter 




a stage more advanced still, the inverted womb may protrude from the 
vulva, — a condition which necessarily involves at least partial inversion 
of the vagina, which is dragged down by the womb. 

Although essentially one of the accidents of midwifery practice, there 
are cases in which the uterus becomes inverted independently of the preg- 
nant state. Most of those are instances in w^hich there is either a poly- 
pus within the cavity, or a fibroid growth in the walls of the uterus, 
which, by acting in a manner as foreign bodies, excite the organ to con- 
tractile and expulsive action, terminating in inversion. It is a disputed 
point whether inversion of the normal and unimpregnated uterus is, in 
any other circumstances, possible. On this point Dr. West says, " In- 
version of the uterus, the turning of the organ inside-out, is an accident 
clearly impossible in the natural condition of the unimpregnated woman, 
— it being obviously essential for its occurrence that the organ should 
have attained a certain size, and that its w^alls should be comparatively 
yielding." This opinion is adopted by Matthews Duncan and others ; 
but Dr. Tyler Smith believes on the other hand, that the unimpregnated 
uterus may invert itself under the influence of irregular contraction. We 
are not aware that any case has been recorded in which the evidence of 
inversion, under such circumstances, is not open to doubt, more or less 
strong. At the same time, we must confess that we agree with Tyler 
Smith's conclusion. It is certainly true, as he says, " that the unim- 
pregnated and virgin uterus, particularly under irritation, possess-es more 
motor power than is generally attributed to it ;" and we can see no physi- 
ological reason which can w^arrant us in assuming such an inversion to be 



CAUSES. 407 

impossible. Many years ago, we had occasion to assist at the post-mortem 
examination of a young woman who had died of fever, and who had suf- 
fered previously to her death from severe flooding. The uterus was found 
completely inverted, and very little, if at all, larger than the normal un- 
impregnated standard. There was neither polypus nor fibroid growth. 
This case corroborates strongly the assertion of Tyler Smith, and, at 
least, proves that previous enlargement of the organ, and a yielding con- 
dition of its walls, are not, as West supposed, essential. There cannot 
be the slightest doubt that the presence of a polypus, or of anything else, 
within the cavity of the uterus must so far encourage inversion, both 
mechanically and physiologically. In the above case, there may have 
been a clot ; but, whether or no, this case and others of an allied nature, 
seem to show that inversion of the unimpregnated uterus may occur, in- 
dependent of polypus, or any other similar condition. 

Causes. — The occurrence of uterine inversion, coincident, as is to be 
feared, very frequently, with the practice of dragging upon the cord 
after the termination of the second stage of labor, has led not unnaturally 
to a prevalent belief that this was the usual cause of the accident in 
question ; and it has also been supposed to be due, in some instances, to 
spontaneous dragging by a funis which is either too short, or has been 
rendered so by twisting round some part of the child. According to 
these ideas, the uterus must be looked upon as a passive agent, the 
fundus or site of placental attachment being mechanically displaced in a 
direction downwards, and ultimately through the os and into the vagina. 
That a certain number of cases are thus produced, most observers will 
probably admit ; but the conclusion arrived at by all who have paid, in 
recent times, most attention to the subject, is, that the importance of this, 
as a cause, has been in every way exaggerated. A strong pull at the 
cord, while the uterus is in a state of flaccidity or complete atony, may 
doubtless — and especially if the placenta be morbidly attached — at once 
turn the organ inside-out. Indeed, if such flaccidity were the normal 
condition of this stage, it would be a matter of wonder that the accident 
should not invariably accompany every eflbrt in this direction ; fortu- 
nately, however, nature here interposes her authority, and eft'ectually 
guards the woman from the efi"ects of operative mismanagement. Nothing, 
as a moment's reflection will show, is so certain, so eftectual a safeguard 
against inversion, as regular and symmetrical contraction of the whole 
uterus. It is well, therefore, that a very common efi'ect produced by 
pulling upon the cord is a contractile action of this nature, by which, for 
the time being, depression or introcession of any part of its walls is 
rendered impossible. Be it observed, however, that this observation 
applies to regular contraction only. 

The uterus does not, in every instance, follow the method of regular 
contraction. On the contrary, it not unfrequently is the seat of irregular 
contractions, which afi"ect certain portions only of the walls, while other 
parts are left in a temporary condition of relaxation or atony. One form 
of this has already been mentioned as a cause of retention of the pla- 
centa by what is familiarly known as "hour-glass" contraction of the 
uterus, and otherwise as " encysted placenta." It would seem as if, in 
the opinion of many, this was the only form of irregular uterine contrac- 



408 INVERSION OF THE UTERUS. 

tion, whereas there can be little doubt that an infinite variety of such 
irregularities may exist. It is, in fact, among such abnormal conditions 
that the true cause of ordinary inversion is to be sought. Many of the 
older writers recognized the presence of such contractions as we now 
allude to ; and one of the earliest observations in this direction was, that 
a frequent site of this localized inertia is that portion of the uterus upon 
which the placenta happens to be implanted. The important bearing 
which this has upon the cause and mechanism of hour-glass contraction 
was clearly pointed out by Levret, although altogether overlooked by 
many subsequent writers. " The neck of the uterus," says Madame 
Lachapelle, " is often inert, although the fundus is contracted ; sometimes 
the reverse happens, and it is then that the placenta, inclosed in the 
uterus, appears to be encysted in it." As the nature of these and other 
abnormal conditions of contraction is more exactly ascertained, the rela- 
tion which they bear to inversion of the uterus comes into view. All 
modern observers agree in the observation that a local uterine paralysis, 
involving, as a matter of course, more or less irregular contraction, occurs 
more frequently at or near the site of the placenta than in any other part 
of the uterus. As this is the part which, by its introcession or depres- 
sion towards the centre of the uterine cavity, forms the first stage of in- 
version, the coincidence of the displacement with the site of local paralysis 
has drawn special attention to the fact. Rokitansky, in his work on 
Pathological Anatomy, says on this point : " We must here mention a 
very singular circumstance, which may, on account of the consequent 
danger, become important, and may even be misunderstood m post-mortem 
examinations ; it is paralysis of the placental portion of the uterus, 
occurring at the same time that the surrounding parts go through the 
ordinary processes of reduction. It induces a \qyj peculiar appearance. 
The part which gave attachment to the placenta is forced into the cavity 
of the uterus hy the contraction of the surrounding tissue, so as to pro- 
ject in the shape of a conical tumor, and a slight indentation is noticed 
at the corresponding point of the external uterine surface." Whether 
the words which we have placed in italics represent or not the real cause 
of the first stage of displacement is a question not as yet definitely 
settled. Matthews Duncan, in his essay on this subject, maintains that 
the uterus cannot itself effect introcession, and that it must, on that 
account, in every instance, be commenced by a force external to the 
uterus. In the case of dragging upon the cord, we have a force of this 
kind acting from below, and, as regards spontaneous inversion, he assumes 
that we have a cause of a similar nature acting from above in the 
mechanical conditions of the abdomen, which are called into play, and 
which take the effective form of what is familiarly known as " bearing- 
down" effort. 

Whatever may be the view entertained as to the initiatory process by 
which spontaneous uterine inversion is effected, numerous authentic facts 
attest that such an occurrence takes place by the operation of causes 
which may be at once abnormal and spontaneous. So soon as the stage 
of depression has been established, as represented in Fig. 136, the fur- 
ther progress of the case admits of easy explanation. The analogy which 
at this stage exists between inversion and an ordinary case of " hour- 



SYMPTOMS. 409 

glass" contraction has not failed to attract the attention of many of the 
more eminent writers on this subject. In both, we find the region of the 
fundus in an abnormal condition of atony, but the parts below are in a 
state of more or less efficient contraction. A stimulus to sustained and 
active contraction is afforded by the presence within the cavity of a 
tumor. "The annular contraction of the body of the uterus grasps," 
says Tyler Smith, "the introcedent fundus as it would a foreign body, 
and carries it downwards for expulsion through the os uteri, the os itself 
being at this time either in a state of inertia, or actively dilated, just as 
at the end of the second stage of labor. After the inverted uterus has 
passed through the dilated os uteri, this part of the organ becomes con- 
tracted, preventing re-inversion from taking place. Thus there is, first, 
the depression of the fundus uteri, with annular or hour-glass contraction 
of the body of the uterus, and dilatation of the os uteri. Xext, there 
is intussusception of the fundus by the body of the uterus. Lastly, com- 
plete inversion occurs, with contraction of the os uteri upon the inverted 
organ. If we wished to describe this action in three words, they would 
be — introcession — intussusception — inversion" (See Figs. 137, 138). 

It must not be supposed that, by thus supporting the doctrine of spon- 
taneous inversion, the production of the accident by artificial or violent 
causes is ignored ; still less, that any support is given by implication to 
the improper practice of pulling upon the cord with the view of effecting 
separation of the placenta. It will be inferred from what has already 
been said, that there are two classes of cases, in one of which the uterus 
is completely, and in the other partially paralyzed. Inertia, therefore, 
in some form or another, is an essential concomitant of all cases of in- 
version. In complete atony of the organ, uterine activity can take no 
part in the displacement, although bearing-down or abdominal effort may ; 
but, in the other variety, where, as has been shown, local paralysis has 
its lisual seat about the fundus, uterine effort is the efficient cause in all 
cases of spontaneous inversion, and in those in which the displacement is 
artificially produced, there is every reason to believe that there must be, 
so to speak, a consenting action on the part of the uterus, which then 
acts in unison with the force which is applied. If any further evidence 
were held to be necessary to establish the fact of such an occurrence, it 
is to be found in the instances which have been put on record of post- 
mortem inversion, which can only thus be satisfactorily explained. 

Si/mptoms. — Inversion generally takes place shortly after the birth of 
the child, often before the placenta has been expelled. The patient being 
thus under the immediate observation of the accoucheur at the moment 
of the occurrence of the accident, the first symptom which will in all 
probability attract his attention is a condition indicating shock, out of all 
proportion to the circumstances even of a lingering or exhausting labor. 
The violence of the shock, and the disturbance of the nervous system 
which accompanies it, bear no relation to the degree of the inversion. 
We would naturally expect that, in the stage of depression or introces- 
sion, the symptoms would not be so severe as in the more advanced 
stages, but in practice this is not found to be the case. The degree of 
constitutional disturbance depends, however, in a great measure, upon 
the amount of hemorrhage, and this again upon the extent to which the 



410 INVERSION OF THE UTERUS. 

placenta has become separated. In all cases in which complete separa- 
tion of the placenta may have occurred, the hemorrhage is alarming, and 
may be so severe as to place the life of the patient within a few minutes 
in most imminent peril. But if the contraction of the cervix is firm, it 
may be by this in some measure controlled. 

The occurrence of such symptoms is accompanied by an unusual con- 
dition of parts, as examined through the abdominal walls. In the stage 
of depression, we may feel the outline of the uterus, but it is no longer 
a spheroid, for its centre presents a cup-like depression which can be 
distinctly felt by the fingers. In the more advanced stage, however, the 
hard tumor which the uterus should in normal circumstances form behind 
the pubes is absent, nor is there in its place any such condition of general 
tumidity as might indicate a flaccid organ distended with blood. The 
uterus has, in fact, passed beyond the reach of the fingers in this direc- 
tion. If we now make a vaginal examination, the nature of the case is 
at once revealed. A firm rounded tumor is here felt, which may also 
protrude externally. If to this the placenta is still partially or entirely 
adherent, there is of course no possibility of error, but when the placenta 
has become separated, no inconsiderable perplexity and difficulty may 
arise. 

The distinction between a fibroid polypus and a partial inversion has 
already been alluded to under the head of post-partum hemorrhage. In 
addition to what was then remarked, we need only observe here that, in 
some cases, the sense of touch affords little reliable information, as there 
is in this respect such variety in the texture both of polypi and inverted 
uteri, that the most skilled observer could scarcely by this alone dis- 
tinguish between the two. The really important point in diagnosis is 
this, that polypi, owing to the narrowness and length of the pedicle, can 
generally be moved much more freely, and may be twisted to a greater 
extent on their long axis without giving rise to any particular pain, while 
the uterine sound can be passed for the usual distance. Any attempt 
which may, on the other hand, be made to twist the tumor which is 
formed by an inverted uterus, is attended with considerable pain, and 
can, m,oreover, be effected only within the narrowest limits, while the 
point of the sound is arrested at a short distance from the os. If there 
is any inherent contractility in the tumor, this at once shows that it is 
the uterus. If the inversion is complete, the continuity of the vagina 
with the lateral w^alls of the tumor enables us by the finger to recognize 
the nature of the case ; but when the intussuscepted fundus is tightly 
grasped by the os and its diameter at this point thereby reduced, the 
resemblance to a fibroid polypus is greatest, and it is here that the tests 
above mentioned may be most usefully applied. The nature of the case 
may be still more conclusively demonstrated by such modes of examina- 
tion as may prove the absence of the uterus from its normal situation. 
On this point, Barnes recommends that we should pass one or two fingers 
into the vagina to the root of the tumor, and then press down the fingers 
of the other hand behind the symphysis. If in doing this we can make 
the fingers meet, and feel from the outside the funnel of the inverted 
uterus, our diagnosis will be confirmed. Or, again, we may pass a finger 
into the rectum so as to get its point above the root of the tumor, and 



TREATMENT. 411 

then pass a sound into the bladder, with its point turned backwards, 
so as to meet the finger in the rectum, which, if it can be aiFected, will 
equally show that the uterus is absent from its usual situation, and con- 
sequently, by inference, that the tumor in the vagina is the uterus. 

Simple prolapsus or procidentia, when occurring immediately after 
labor, may also be mistaken on a careless or cursory examination for in- 
version, but more careful observation will at once in such cases disclose 
the real nature of the case, as soon as the depression corresponding 
to the OS or the orifice itself is recognized in the centre of the projecting 
tumor. 

The symptoms above enumerated are those of an ordinary case of 
uterine inversion, occurring in the course of labor, and do not, of course, 
apply in all respects to the other and rarer varieties. Assuming it for 
the moment as proved, that inversion of the unimpregnated organ is a 
possible occurrence, it is undoubtedly so rare that little or nothing can 
be said as to its symptoms ; but we may assume that hemorrhage, pain, 
and nervous shock will be among them, and that the diagnosis may be 
unusually difficult. There may be cases, again, in which the presence 
of a polypus is established, and yet inversion may occur, the two condi- 
tions thus coexisting, although the former has in all probability been the 
direct cause of the latter. There are yet other instances in which inver- 
sion may succeed delivery, and yet not follow so closely upon it as it 
usually does. Possibly, in such the initiatory stage of depression has 
alone been produced during labor, and this again has been transformed 
into one or other of the more advanced stages by irregular contractions, 
or modifications of what are known as after-pains. It would appear as 
if occasionally the symptoms, at the time of the inversion, were not so 
marked as usual ; for there can be no doubt that the accident has some- 
times been altogether overlooked at the time of labor, and only discovered 
long after. When the woman recovers from the immediate effects of in- 
version, she may regain her health and strength as if nothing ailed her, 
and be able to follow her ordinary avocations. But in such cases, the 
original symptom of hemorrhage will, sooner or later, return, and by its 
periodic recurrence — corresponding often, as might be anticipated, to 
catamenial periods — saps the strength and undermines the health of the 
patient. These constitute cases of Chronic Inversion. 

Treatment. — Whatever the stage may be at which inversion of the 
uterus is recognized, our duty is to reduce the dislocation of the fundus 
without unnecessary delay. If we were fortunate enough to discover 
what has happened immediately, there would probably be but little diffi- 
culty in effecting the reposition, as we would then find the os in a state 
of relaxation. This period is, however, of brief duration, and is followed 
by contraction of the os, which grasps the organ firmly, and in this way 
adds very greatly to the difficulty of the operation. 

If the placenta is still adherent, it is a question whether we should at 
once separate it. The advantage of the procedure is, that the fundus 
will undoubtedly be more easily reduced than when its bulk is increased 
by the presence in its immediate neighborhood of the mass of the pla- 
centa ; while, on the other hand, the obvious disadvantage of separation 
is to encourage hemorrhage by rupturing the utero-placental vessels. 



412 INVERSION OF THE UTERUS. 

Both methods of treatment have been adopted, but it is certain that 
neither of them can be held as appropriate to all cases. Reposition 
along with the placenta is, in fact, only applicable to those cases in which 
the OS is relaxed, and is all but impracticable in the other class of cases, 
where we may find it difficult enough to return the fundus alone through 
the stricture formed by the os. Practically, the question may be said 
to stand thus : return the placenta if you can, or attempt to return it, if 
you can see a reasonable prospect of doing so without the exercise of 
undue force ; otherwise, separate the placenta at once, and do not waste 
time which may be of inestimable value in the interests of your patient. 
To remove the placenta from its attachments, insert the finger beneath 
the edge, and gradually strip it from the entire surface to which it is 
adherent. The diminished size, and at least partially contracted condi- 
tion of the uterus, lessen to a considerable extent the danger which we 
would naturally anticipate from hemorrhage ; but the risk is still suffi- 
cient to render it imperative that we should make no delay at this stage, 
but proceed at once to the reduction. 

The method which is usually recommended is to bring the points of 
the fingers together, and to apply the apex of the cone thus formed 
firmly to the centre of the displaced fundus, which is by this means to 
be steadily pushed upwards in the axis of the pelvis, so as to carry the 
fundus through the ring formed by the contracted os. Due caution 
must, of course, be exercised in regard to the amount of force which is 
employed, as it is possible by violence to inflict very considerable injury 
upon the uterine tissue. So soon as the fundus passes through the os 
in the process of re-inversion, it must be followed upwards by the finger, 
to render the operation complete. While this is being effected, the 
organ is to be steadied, as far as is practicable, by the hand placed upon 
the abdomen, and the operator must, in addition to this, be careful to 
direct the force to one side or other, so as to avoid the sacral promon- 
tory. Another method which has often been successfully adopted is to 
imitate the process for the reduction of a hernia by compressing the 
tumor laterally, and returning the cervix first and the fundus after- 
wards. 

When a certain time, even a single hour, has elapsed since the dis- 
placement has taken place, the difficulties of the operation may be con- 
siderably increased ; and when this has extended to days, it will naturally 
become more difficult still. The effect of the strangulation of the neck 
of the tumor is to cause general tumefaction of the parts beneath, so that 
it will often be necessary to compress the organ from side to side, in 
order to curtail its dimensions in that direction before attempting actual 
reduction. By this manoeuvre a difficulty, which may at first seem in- 
superable, will sometimes be overcome. By the ordinary procedure, by 
means of the fingers, the reposition of the uterus has been found by some 
operators to be so difficult that instruments have been used which, being 
of less bulk, are presumed to offer certain mechanical advantages. Of 
such a nature is the hdton repoussoir of Depaul ; but to this it may 
fairly be objected that the gain is probably more than counterbalanced 
by increased risk; and it must be confessed, in this, as in many other 
operations in midwifery, that the more experienced and skilful the ac- 



TREATMENT OF CHRONIC INVERSION. 413 

couclieur, the more does he prefer his fingers to mechanical aids, how- 
ev^er ingenious. 

When the fundus has passed to a certain distance ^vithin the os, it has 
very frequently been observed that the same muscular action of the 
uterus which originally contributed to the dislocation of the organ now 
comes into play as an auxiliary to reposition, and it is not uncommonly 
observed that the ultimate complete restitution of the fundus is effected 
by a sudden jerk or snap, which is often quite audible to the bystanders. 
In those instances, however, in which inertia of the organ is persistent, 
it will be necessary to pass the hand quite w^ithin the cavity, until we 
are convinced that its anatomical relations are completely re-established. 
Nor is it proper, at this moment, and at once, to withdraw the hand. 
We should rather act here as we would do in a case of encysted pla- 
centa, or of post-partum hemorrhage, in which the hand is introduced for 
the removal of the uterine contents; and it is, therefore, advisable to 
allow it to remain in contact with the uterine walls, and to act with the 
other hand, in concert with it, through the abdominal walls, so as to ex- 
cite the organ to efficient and symmetrical contraction, which is a safe- 
guard both against hemorrhage and a repetition of the displacement. 

There is another class of cases, in which the difficulties are still more 
formidable than any which have hitherto been described. It may be 
assumed that the longer the standing of the case the more serious will 
be the obstacles to reduction, until it reaches the condition to which the 
name Chronic Inversion has been given. Where, it may be asked, may 
we assume acute inversion to end, and chronic inversion to begin ? The 
only rational reply to this question with which we are acquainted, is that 
which is given by Dr. Barnes — " I would distinguish the cases in this 
way : inversion is recent so long as the physiological process of involu- 
tion of the uterine tissues is going on. When this process is complete, 
and the uterus has returned to its ordinary condition, the inversion is 
chronic." 

It was at one time generally supposed that, when a few hours had been 
permitted to elapse, inversion might be looked upon as irreducible. The 
results of modern practice have, however, clearly demonstrated that such 
an idea is quite untenable ; and it may now be confidently asserted, that 
no condition short of inflammatory adhesion of the parts will warrant 
such a conclusion, whatever the duration of the case may be. The 
great point to be kept before us, and against which all operative effort is 
to be directed, is the contracted state of the os. However hopeless, 
therefore, on a cursory examination, the case may seem to be, we may 
be confident that sustained effort will, in the end, overcome the resistance. 
But, to be effectual, it must be continuous ; and we have only to reflect 
upon the fact that Tyler Smith succeeded thus in reducing an inverted 
uterus of ten years' standing, and that a number of cases are on record 
of a similar kind, to encourage us, even under the most unpromising cir- 
cumstances, in diligent and untiring effort. 

Pressure effected by means of the hand of the operator, although 
perfectly safe, cannot be maintained for a sufficiently long period, and 
is thus inapplicable to the class of cases which we are now considering. 
The very obvious danger which Avould attend the use of any solid mate- 



414 INVERSION OF THE UTERUS. 

rial, has led to the employment of air or Avater bags, which are to be 
introduced into the vagina, and gradually distended. This elastic pres- 
sure is, when properly applied, perfectly safe, and can usually be borne 
by the woman without much uneasiness. In Tyler Smith's case, above 
referred to, the details of which will be found in the " Medico-Chirurgi- 
cal Transactions" for 1858, the pressure was kept up for more than a 
week; and, in many other cases, a similar process has been attended with 
equally satisfactory results. The mode of action in these seems to be 
that continuous although indirect pressure is thus brought to bear upon 
the OS. At first, this is as ineffectual, or even more so, than the previous 
efforts, which have already been made with the view^ of effecting reduc- 
tion by manual interference ; but, in the end, the long-continued pressure 
wears out the spasm, the os yields, and re-inversion occurs. 

In those instances in which it is said that the organ has been spon- 
taneously restored to its normal condition, as in a case narrated by Bau- 
delocque, it is certain that a spontaneous relaxation of the os must have 
occurred, and it is probable that, along with this, the inverted organ had 
been subjected to some pressure in its new situation from permanent or 
temporary causes. The theory that a spontaneous reduction may take 
place in consequence of tonic contraction of the Fallopian tubes and of 
the broad or round ligaments, appear to us to be' in the highest degree 
improbable. The condition, of all others, essential to replacement is, we 
repeat, relaxation of the os. There may be cases, however, in which 
even sustained elastic pressure may fail to effect the object which we have 
in view, although we have every reason to believe that such must be of 
rare occurrence. But, even under such circumstances, our resources are 
far from being exhausted, and various methods have been adopted for 
overcoming the difficulty in individual cases, which it would be impossible 
to describe here. The idea of section of the constriction must have often 
suggested itself ; but Dr. Barnes was probably the first to carry a case 
to a successful termination by this operation. ^ The proceeding, as de- 
scribed by him, is as follows: " Draw down the uterine tumor by means 
of a loop of tape slung round the body, so as to put the neck of the 
tumor upon the stretch ; then, with a bistoury, make a longitudinal inci- 
sion about half an inch long, and a quarter of an inch deep, on either 
side, into the constricting os ; then re-apply the elastic pressure. Next 
day, try the taxis, and re-apply the elastic pressure if necessary. Elastic 
pressure alone, or aided by this operation, will, I am convinced, overcome 
every case of inversion, except when fixed by inflammatory adhesions." 
Another, and probably a safer, process has also been suggested, by which 
the incisions in the os are increased in number, but made much more 
superficial. 

Cases have been met with in Avhich menstruation has gone on regularly 
from the surface of an inverted uterus ; and, indeed, observation of such 
instances has thrown some light upon the source of the menstrual dis- 
charge. In such cases, leucorrhoea, and the presence of a tumor within 
the vagina, may be the only symptoms, but the almost invariable rule is 
repeated flooding, and that to such an extent as to bring the patient into 

' Medico-Cliirurgical Transactions. 1869. 



REMOVAL OF UTERUS. 415 

a conrlition of immediate danger. Failing all the means already de- 
tailed — in which we may assume that full advantage has been taken of 
anaesthetic agents, which are invaluable in all cases of uterine spasm — 
is there any other method which we may adopt for the relief of a woman 
who may be dying before our eyes from the effects of this accident? 

The only possible remedy in such a case is removal of the inverted 
uterus, as this alone can be expected effectually to check the hemorrhage. 
The objections to such a procedure are sufficiently manifest ; for not only 
is the case one of mutilation, by which the woman is unsexed, but it is 
one the immediate risk of which is very great. Still, the operation 
has been performed with success, and the woman has enjoyed per- 
fect health for many years thereafter. In the only case which has 
come under our observation, the patient, who was operated upon many 
years ago, is still alive, and in perfect health ; and it is worth remark- 
ing, in addition, that she never menstruated after the operation, but 
that the menstrual molimen, which regularly occurred for some years, 
was apparently relieved by periodical or vicarious leucorrhoea. When, 
therefore, the doom of a patient seems fixed if we decline to interfere, 
we should have no hesitation in resorting to a measure so extreme as the 
removal of the organ; and, of course, at the present day the operator 
would select the e^raseur in preference to the older methods of ligature 
or excision. The best instrument for the purpose is the wire-rope e^ra- 
seur of Braxton Hicks, which may be used either with fine wire twisted 
into a rope as recommended by the inventor, or with a single strong wire 
as is recommended by Barnes. The responsibility which' attaches to an 
operation such as this cannot fail to weigh upon the operator ; and he 
will, therefore, at once recognize the necessity, before finally committing 
himself to this course, of making himself sure on two points: first, as 
to the accuracy of his diagnosis ; and, second, that the tumor is beyond 
all doubt irreducible. Until we can form a confident opinion in regard 
to both these matters, we cannot, in any case, conscientiously proceed to 
operation ; and it must also be borne in mind that the more perfectly has 
our knowledge of the accident become developed, the more completely has 
the operation for removal of the organ fallen into disuse and disfavor. 

[Extirpation of the uterus under these circumstances is frequently 
fatal. About one-third of all the cases end in death. It is besides a 
mutilation, from which the patient and her surgeon naturally revolt. 
Prof. T. G. Thomas has proposed and successfully practised another 
method of cure in a very obstinate case of chronic inversion, in which 
Professors Miller, of Kentucky, and Parvin, of Indiana, as well as him- 
self had failed in effecting reduction after prolonged and repeated efforts. 

Under these circumstances Professor Thomas proposed to reduce the 

displacement by making an incision in the abdominal wall, and stretching 

the cervical constriction. For this purpose the patient is to be thoroughly 

etherized, when an assistant passes his hand into the vagina, and seizing 

the inverted fundus, lifts it up so that the cup-shaped depression can be 

felt ao;ainst the abdominal wall. An incision about two inches lono- is 

... ^ 

then made in the median line ; all the precautions recommended by ova- 

riotomists being carefully observed, so that no blood is admitted into the 
peritoneal cavity. The peritoneum being opened, the operator then re- 
places the hand of his assistant with his own in the vagina, as is shown 



416 



INVERSION OF THE UTERUf 
Fig. 139. 




Thomas's Method of Eeduciug Chronic inversion. (After Thomas.) 



in the figure. He then stretches the constricted cervical ring with an 
instrument resembling a glove-stretcher. After this is completely dilated, 
the inversion is to be reduced by one of the various methods of taxis. — P.] 



CHAPTEE XXYI. 

RUPTUKE OF THE UTERUS. 

Rupture during Pregnancy. — Rupture during Labor. — Partial or Incomplete Rup- 
ture. — Site, Extent, and Direction of the Laceration. — Reason of the Com- 
parative Lrequencg of Cervical Rupture. — Is Rupture less common in Primi- 
paroe'? — Effect of the Duration of Labor. — A. Mechanical : Sex; Pelvic 
Deformity ; Faulty Presentation ; Pressure upon the Cervix; Operative Vio- 
lence; Ergot; Violent Uterine Action. — B. Reflex: Excitement of Cervix, etc. 
— C. Pathological: Cancer; Rigidity of the Os ; Thinning or Partial Atro- 
phy ; Softening; Fatty Degeneration. — Premonitory Symptoms: Localized 
Pain increased during Labor. — Signs of Rupture: Pain; Hemorrhage; 
Shock; Recession of the Presenting Part. — Lacerations involving the Vagina. 
— Treatment. — Preventive Measures : Delivery by the Forceps or by Perfora- 
tion: Extraction of the Placenta. — Hernia of the Intestine. — Treatment, if 
Foetus has escaped into the Peritoneal Cavity. — Further Management of the 
Case. — Treatment of Rupture of the Uterus in various Stages of Pregnancy. 

Rupture of the Uterus, at all times one of the most appalling acci- 
dents of midwifery, is also the most fatal; and is the more terrible, as 
in many cases it can neither be foreseen nor averted. The elaborate 



RUPTURE DURING PREGNANCY. 417 

statistics for which "we are indebted to Dr. Churchill, show the accident 
to have occurred in 85 out of 118,138 cases of labor — about 1 in 1331. 
Although it is almost always during labor that rupture occurs, it is not 
always so, and a certain number of well authenticated cases are recorded, 
in which rupture occurred at various periods in the course of pregnancy, 
in the absence of any uterine action whatever. Some of these cases 
have been the result of violence, and a considerable number seem to have 
followed over-exertion of some kind. But there are others in which no 
such cause can have been in operation, as in a case published in the 
3Iedical Repository by Mr. Scott of Bromley, in which a woman, in the 
sixth month, was awakened from sleep by a sudden pain about the 
umbilicus, which was soon succeeded by collapse and death. On exami- 
nation, after death, a rupture was discovered at the fundus, through 
which the foetus, enveloped in its membranes, had escaped into the abdom- 
inal cavity. It would probably be impossible, in many of these cases, 
to distinguish between this accident and rupture of the sac of an extra- 
uterine pregnancy, as the symptoms are, in the two cases, almost identi- 
cal. The very rarity of spontaneous rupture has not unfrequently given 
rise to suspicion of foul play in such cases, and the question has, there- 
fore, a medico-legal significance, in reference chiefly to criminal abortion; 
but there will probably be little difficulty in recognizing a rupture occur- 
ring spontaneously in the course of pregnancy, seeing that it generally 
occurs at the fundus, while criminal injuries are more frequently discov- 
ered in the region of the os and cervix. Besides, the nature of the 
injury is so different that the appearance of a spontaneous rent and a 
violent laceration could scarcely be mistaken ; and, moreov^er, there often 
is to be found, as the cause of these ruptures, a diseased condition of the 
structures of the womb. Ruptures during the course of pregnancy may 
occur as early as the third month, but are more frequent, the more ad- 
vanced is the development of the foetus. 

By far the greater number of cases occur during labor, and it is to 
these that attention must be more particularly directed. The laceration 
in those cases generally involves the entire thickness of the uterine walls, 
but there are exceptions to this rule. In some, the rent is found to have 
extended through the mucous membrane and proper tissue of the uterus, 
and to have been arrested by the peritoneum, which remains intact. 
The mobility of the peritoneum upon the subjacent uterine tissue in some 
measure encourages this; and it is, therefore, at the lower portion, 
where the connection of the peritoneum is looser, that this has been more 
frequently observed. The result of such cases, although often fatal, is 
not so much to be despaired of as when the laceration is complete ; but 
a very probable result would be the effusion of blood between the perito- 
neum and the tissues beneath, and the consequent formation of peri- 
uterine hematocele. In many of these instances, it is most likely that 
the fact of laceration is not recognized at all at the time of its occurrence. 
Another rare variety of rupture consists in numerous fissured lacerations 
of the external surface of the tissue proper of the uterus, immediately 
beneath the peritoneum, which may give rise, as in the other case, to 
subperitoneal hemorrliage ; while, in other instances, the peritoneum 
27 



418 RUPTURE OF THE UTERUS. 

itself is the only part which is lacerated, the other tissues escaping alto- 
gether. 

Any part of the uterus may be the seat of laceration, while the rent 
in the tissues may take any direction, and, in extent, may be limited only 
by the size of the organ itself. It may thus be either longitudinal or 
transverse ; and may, in the first case, correspond to the entire length of 
the uterus, and, in the latter, the laceration may extend completely 
around the uterus, thus dividing it into two. Both of these are extreme 
cases : the rent is generalh^ much more limited in extent. Considerably 
more than half of all the ruptures at the full time occur in the region of 
the cervix, generally at that part which marks the junction between the 
uterus and the vagina. Next in point of frequency comes the body ; 
and last of all, the fundus, which is, as we have seen, the site preferred 
in early pregnancy. One of the most remarkable monographs on this 
subject is one which was published, in 1848, in the American Journal of 
the Medical Sciences^ by Dr. James D. Trask, and is based on an analysis 
of over four hundred cases. The following represents the proportion of 
cases in the various situations named, as deduced from his statistics : — 

Ruptures of the Cervix 55 per cent. 

" Body 36 " 

" " Fundus ..... 9 " 

The reason of the comparative frequency of rupture at the cervix is 
afforded by a moment's consideration of the mechanism of the dilatation 
of the OS, which has been fully detailed in reference to the progress of 
the first stage of labor. The os, as was explained, is dilated by the com- 
bined action of the longitudinal fibres of the uterus and the bag of waters, 
or, in the absence of the latter, by the presenting part of the child ; so 
that we cannot wonder that the usual seat of rupture is where the 
greatest amount of force is brought to bear. Trifling raptures of the 
vaginal portion of the cervix, commencing at its margin, are among the 
most common of the minor accidents of midwifery. But, even when 
lacerations of this part are more extensive, the rent does not necessarily 
involve the peritoneum, so that the gravity of the case will depend chiefly 
upon whether or not that membrane is injured. In some rare instances, 
the laceration extends into the bladder, and in others, rarer still, the 
whole vaginal portion of the cervix has been separated, in the form of a 
ring, which has been born with the child. Lacerations of the cervix 
alone are very common, and generally take a vertical direction. They 
are said to occur more frequently on the left than on the right side. 

It was at one time generally supposed, and it is even now stated by 
many writers, that there is less liability to rupture in first than in sub- 
sequent pregnancies. A more correct observation of such statistics as 
bear on that subject — among which those of Churchill and Trask are 
best known — sliow that this is not the case, but that there is, if anything, 
a preponderance of primiparous cases. Another view all but universally 
held, was that the accident was a common result of protracted labor ; 
and it is, indeed, not unnatural to suppose that this should be the case ; 
but there is, perhaps, no one point which is brought out more strikingly 
in Dr. Trask's cases than that the actual duration of labor has little or 



CAUSES. 419 



m 



nothing to do Avith it. In 104 out of 147 cases rupture occurred witlii 
twenty-four hours of the commencement of labor. It must, however, be 
remembered that the usual issue of a protracted case is failure of the 
pains ; so that, although we may fairly assume that long-continued effort 
would endanger tissues weakened by exhaustion, nature here arrests the 
pains, and thus interposes for the protection of the parts, vigorous action 
being only restored when she has had time to recruit her exhausted 
powers. 

Causes. — Whatever views may be entertained in regard to the two 
conditions above alluded to, there can be no doubt that anything which 
mechanically impedes the course of labor, is an undoubted cause of 
rapture of the uterus. The sex of the child thus plays, as might be ex- 
pected, an important part, as is shown by the statistics of the Dublin 
Lying-in Hospital, extending over a long period, from which it would 
appear that, in nearly 70 per cent, of all the cases of rupture, the sex 
was male. Trask's cases show, no less clearly, that pelvic deformity, or 
disproportion is another important cause, wdiich had been proved to exist 
in 74*74 per cent, of his cases. For the same reason, faulty presenta- 
tions, which are an impediment to labor, may be the direct cause of 
uterine rupture ; thus, in 303 cases given by Trask, of all presentations, 
16 were presentations of the shoulder. Forcible compression of the neck 
of the womb between the head of the child and the pelvic walls is sup- 
posed by Dr. Murphy to play an important part in inducing rupture of 
the womb, so that if it is pinched anteriorly against the ilio-pectineal 
line, or posteriorly upon the promontory of the sacrum, anterior or pos- 
terior lacerations of the cervix are to be explained by the mechanical 
action of the longitudinal fibres. 

Although we have every reason to believe that the more accurate 
knowledge of modern times has had a marked effect upon the results of 
modern practice, it must still be admitted that operative violence cannot 
be overlooked as a cause of rupture of the uterus. AVe do not here refer 
to such cases as occur in consequence of causes of a pathological nature, 
to which we shall again advert, wdiere the accoucheur is often unjustly 
blamed ; but to those in wdiich errors of judgment, or rashness in operative 
procedure, lead to this disastrous result. The most common of all mid- 
wifery operations, for example, may, in any case, be attended Avith 
extensive laceration ; for if we apply the forceps without due considera- 
tion, and careful observation of the state of the os, we may readily rend 
those tissues and destroy our patient. In the same way, clumsy manipu- 
lation in turning — more particularly when the liquor amnii having 
escaped, the uterus is firmly contracted upon the child — may, at any 
stage of that operation, in a moment plunge a satisfactory case into the 
category of hopelessness ; and so, in a hundred different ways, operative 
incompetency may, in the attempt to shield the woman from danger, only 
precipitate her doom. The improper administration of ergot has, there 
is only too good reason to believe, been attended with a similar result in 
no insignificant number of cases, w^here that powerful drug has been given 
in tedious cases, without any reference whatever to the amount of me- 
chanical resistance which has to be overcome ; and we rather think, that 
if the truth were known — which, for obvious reasons, is often w^ithheld — • 



420 RUPTURE OF THE UTERUS. 

this, as a cause of uterine rupture, would stand prominently forward. 
Professor Bedford of New York has in his museum four wombs ruptured 
by the improper use of ergot. A preternatural violence in the uterine 
contractions, even when associated with no marked resistance beyond 
Avhat is perfectly normal, may also induce rupture by the actual impetu- 
osity of the propulsive effort ; but such cases, in the absence of morbid 
excitement of some kind, are probably very rare. When such morbid 
excitability does exist, it is astonishing, however, by what trifling causes 
violent action may be set up. It is by no means rare, that the slight 
irritation of the cervix which occurs in the course of an ordinary vaginal 
examination, arouses, by a reflex act, an amount of expulsive effort 
which may thus lead to rupture from a cause apparently so simple. Ex- 
amples of this kind have been from time to time recorded, but cases 
which are centric in their origin are, undoubtedly, of far more frequent 
occurrence. Rupture has occasionally taken place, or has been extended, 
during straining at stool. 

Special attention has of late years been directed to certain pathologi- 
cal conditions, upon which there can be no doubt that rupture of the uterus 
occasionally depends. It is in these cases mainly that, in the most skil- 
ful hands, and with every possible attention, ruptures quite unexpectedly 
occur ; and in such the practitioner may be cruelly and unjustly blamed. 
This, indeed, is by no means the lest important of the considerations, 
which invest this part of the subject with a special interest. Some of 
the pathological conditions referred to also act, like the class of cases 
already mentioned, mechanically. Of this nature is cancer of the uterus, 
which generally attacks the os and cervix, and unfortunately, in some in- 
stances, proves no bar to conception. The nature of the disease, even 
when it has not passed to the more advanced stages, renders the affected 
tissues so undilatable, that laceration, under the influence of efficient 
uterine contraction, is almost inevitable ; and, in more extreme cases, the 
only safeguard may be Craniotomy or the Csesarean Section, Cases of 
extreme rigidity of the os and of the more external parts of the partu- 
rient canal, are by no means of rare occurrence in practice ; and, if they 
should chance to be accompanied with, or complicated by, violent uterine 
effort, rupture may not unlikely occur. There are, however, other con- 
ditions in which laceration may take place quite independently of exces- 
sive muscular action, or even in the absence of such action, as the history 
of uterine ruptures during pregnancy and before labor seems to show, 
and the interesting researches of Dr. Murphy at the Dublin Lying-in 
Hospital, clearly demonstrate. " Thinning, or partial atrophy of the 
uterus, is not an unfrequent cause, says Dr. Murphy ; " four examples 
of this morbid change presented themselves to our notice. . . . When 
a change of this kind takes place, the symptoms are often very obscure. 
There may be a very severe laceration without any severe pains, or any 
of those prominent symptoms that often precede the accident. You can 
appreciate what would be the effect of ergot of rye, if it were given to 
increase pains rendered feeble from this morbid condition of the uterus. 
Softening is another pathological cause of laceration. The fibrous tissue 
seems to be the first tissue affected ; the mucous membrane may then be 
involved, but the peritoneum generally escapes. This morbid change may 



SYMPTOMS. 421 

be only slight, affecting a few of the uterine fibres ; or it may be exten- 
sive, converting the affected portion of the uterus in a putrid mass. Thus 
we have found a kind of aneurismal sac formed in the parietes of the 
uterus, in consequence of a partial rupture of the uterine fibres ; no 
symptoms of laceration showed themselves during labor, nor did any ap- 
pear until several hours afterwards, when the sac burst. In the same 
manner may be explained some of those obscure cases of sudden and 
fatal hemorrhage some days after delivery. Dr. Collins relates one in 
which the patient was seized with violent flooding on the fifth day after 
delivery. She died in an hour ; and on dissection, it was discovered that 
a patch of the uterus, of about the size of a shilling, had given way, 
corresponduig to the projection of the sacrum." 

Recent observations tend to show that that process of fatty degenera- 
tion which, as we have shown, is so essential a phenomenon of the normal 
process of involution (see Fig. 132), sometimes takes place prematurely; 
and, if so, it can be readily understood how such an occurrence — under 
the circumstances, of course, a pathological one — must essentially con- 
tribute to the risk of rupture. And there can be little doubt, as Tyler 
Smith observes, " that in cases where the uterus is feebly developed, or 
weakened by disease and exhausted action, the contractions of the ab- 
dominal muscles must contribute to the rupture of the organ, by urging 
the head or presenting part of the child through the os uteri." 

Symptoms, — The causes of rupture of the uterus being so various, it 
will excite no astonishment that the symptoms are far from being uniform. 
Yery violent and tetanic uterine contraction, under circumstances which, 
for the time at least, render it impossible that labor can make much pro- 
gress, will always excite our apprehension, and may seem to call for such 
means as we have at our command for moderating excessive action. But, 
the powers of nature are such that, even in the most unpromising circum- 
stances, the dreaded result seldom ensues. The significance of the premoni- 
tory symptoms is, however, greatly increased if, along with contractions 
of this nature, the woman complains of pain of an unusual intensity ; and, 
if the site of such pain should correspond to a point where it had been 
complained of before labor, our fears will be proportionally increased. 
We cannot, however, trust to premonitory symptoms. Indeed, in the 
great majority of cases, we have not even the benefit of such obscure 
signs as have been mentioned, and thus the climax of the case is attained 
while we are quite unprepared for a casualty so dreadful. 

As a general rule, the symptoms which denote actual rupture of the 
uterus are well marked. At the height of a pain, a sudden and excru- 
ciating pang may occur. This is sometimes accompanied with a snap 
which may be audible to the patient and even to those about her. The 
pain suddenly ceases, and is almost instantly followed by alarming pros- 
tration and shock, which is modified, more or less, by the characteristic 
symptoms of hemorrhage. This may be altogether internal, or may be 
indicated by a gush of blood from the vagina, according to the portion 
of the uterus which has been the seat of the rupture. The countenance 
becomes pallid, with a fearful expression of alarm and anxiety ; the face 
is bedewed with a clammy sweat, and the extremities and general surface 
become cold. The stomach ejects its contents, and at once throws off 



422 RUPTURE OF THE UTERUS. 

anything which may be swallowed ; and it has sometimes been noticed, 
after protracted retching, that the matter vomited is of the color and ap- 
pearance of coifee-grounds. The respiration becomes labored, and the 
pulse becomes rapid, feeble, irregular, and ultimately imperceptible. 
Simultaneously with these symptoms, the signs of the life of the foetus 
disappear. In some cases, the occurrence of rupture is not marked either 
by acute pain or by the other symptoms above enumerated ; and the dan- 
gerous condition of the patient may only become apparent after a con- 
siderable period has elapsed, it may be hours, or even days. These are, 
for the most part, cases in which the rent is comparatively trifling in ex- 
tent ; and, if it should so happen that the entire thickness of the uterine 
tissues has not been involved, the ordinary expulsive contractions may go 
on, although probably modified in degree. 

A very usual and significant symptom is recession of the head of the 
child, which may have come to press on the perineum, or even to distend 
the vulva. If along with symptoms such as have been described, the head 
suddenly recedes towards the upper part of the pelvis or passes beyond 
the reach of the finger, we can have little doubt as to the nature of the 
occurrence. We must here warn the young practitioner against an error 
into which he may fall, and which may cause him considerable amount of 
unnecessary anxiety ; for it not unfrequently happens, towards the ter- 
mination of the second stage of labor, that the head suddenly and unex- 
pectedly recedes, on the termination of a pain, to a much greater extent 
than is usual. Such an occurrence, however, need cause no alarm, as it 
is due to a mere temporary relaxation of the uterine walls, and is usually 
the forerunner of more efficient contractile efforts, under the influence of 
which the child is rapidly brought into the world. Complete recession 
of the presenting part, in rupture of the uterus, usually indicates that 
the child has passed or is passing through the uterine v^alls into the 
cavity of the abdomen, through the parietes of which the various parts 
of the child may be distinguished. In some cases, it would appear that 
the sudden cessation of labor "pains was the only symptom of any im- 
portance, and it is worth remembering that this has been mistaken for 
inertia, and ergot administered. 

There is a class of cases which, although not strictly speaking ruptures 
of the uterus, have so important an analogy to the latter that it seems proper 
to mention the subject here. These are ruptures or lacerations of the vagina. 
Lacerations of the vagina are usually situated in its posterior wall, and, 
when in the lower part, are sometimes complicated by rupture of the peri- 
neum, more or less extensive. There are instances, however, in which the 
rupture of tissue is very extensive in so far as the vagina is concerned, 
and in which, nevertheless, the external tissues of the perineum remain 
quite uninjured, such cases proving both tedious and troublesome, although, 
as compared with rupture of the uterus, they are comparatively free from 
danger. The lacerations to which allusion is here more particularly made, 
in reference to uterine rupture, are those in which the head of the foetus 
after passing the os, pinches in and compresses a zone of the vagina. 
The uterus in its contractile efforts pulls upon this fixed ring, precisely 
as happens when the cervix is similarly compressed, the result being a 
tear which is transverse in its direction, and may extend circularly 



TREATMENT. 423 

around the entire vagina. It is important to know that, in such cases, 
the whole of the uterus with the upper part of the vagina has been ex- 
pelled by the natural efforts, which has given rise to the charge of mal- 
apraxis. It has been denied by some that the uterus could in this way 
rend its ligaments ; but recorded and perfectly authentic cases now 
clearly show that not only may the round and broad ligaments be torn 
asunder in this way, but that they may even be ruptured as a mechanical 
effect of spontaneous inversion. Lacerations involving both vagina and 
uterus are not uncommon, and it is probably difficult in some of these 
instances to determine for certain in which of the two textures the rupture 
has had its origin; but there can be no doubt that lacerations, either of 
the cervix uteri or of the upper part of the vagina, must, in consequence 
of their intimate anatomical relations, be very apt to extend from the one 
to the other. A considerable hemorrhage could scarcely fail in such 
cases to be a prominent symptom. 

The most serious cases of rupture of the vagina are those in which the 
rent occurs in the region immediately behind the os, as this involves a 
communication with the cavity of the peritoneum. Recently, particular 
attention has been called to this accident by Dr. Galabin and others,^ 
and cases are recorded in which the child and placenta have passed 
through an aperture in this situation, the tissues of the womb remaining 
intact. 

Treatment. — It is scarcely necessary to observe that, if there be any 
possible means whereby we may succeed in preventing this accident, 
such must necessarily be by far the most important point relative to 
treatment. But, unfortunately, the indications which demand preventive 
treatment are so obscure in their nature that it is difficult to tell, on the 
one hand, whether we are called upon to interfere, and, on the other, 
whether, having interfered, the safety of the patient may fairly be attri- 
buted to our conduct in the case. The latter point is perhaps the most 
difficult of all. We recognize, let us suppose, a serious mechanical im- 
pediment to delivery, which coexists with violent and long-continued 
uterine effort, and which may seem to imperil the integrity of the uterine 
tissues. We operate, by the forceps, turning, or otherwise, and speedily 
relieve the patient; but when are we entitled to say that such prompt 
and decisive action on our part has actually averted a great calamity ? 
We may, indeed, be perfectly certain that a well-considered and definite 
plan of treatment, in accordance with which operative assistance is 
afforded or withheld, will reduce rupture of the uterus to a minimum, as 
is well shown by the statistics of large lying-in hospitals, where this 
accident is one of those least frequently met with. It cannot, however, 
on the other hand, be doubtful that a needless dread of rupture, which 
inexperience is certain to exaggerate, leads in some instances to opera- 
tive interference, which may be perfectly unnecessary, although the 
operator does not fail to congratulate himself on a fortunate issue, which 
he fancies to be due to his prescience and skill. 

Apart from this, there are, hoAvever, certain conditions upon which an 
intelligent preventive treatment may be founded. The occurrence, for 
example, in the course of gestation, of acute pain, referable to some 

' See Transactions of the Obstetrical Society. London, 1878. 



424 RUPTURE OF THE UTERUS. 

particular part of the uterus, has often been known to precede rupture 
in the part affected, which is believed in these instances to have been 
the seat of local or limited metritis. Should any suspicion, therefore, of 
this be entertained, it will be proper to adopt such means as may seem 
suitable with the view of subduing the morbid action which is assumed to 
exist. One, and by no means the least important, of the objects which 
the accoucheur has in view in inducing premature labor in cases in which 
there must be disproportion of parts at the full time, is to avert the 
danger of rupture which fruitless uterine effort might in any case pro- 
duce. And he will, in like manner, feel himself impelled to prompt and 
energetic action, when the expulsive effort of the uterus is morbidly in 
excess. In some of these cases, the contractions attain a tetanic vio- 
lence, which seems at every moment to imperil the integrity of the 
uterine tissues ; and, if the period should not have arrived at which we 
may assist delivery by artificial means, we must then have recourse to 
such treatment as may subdue this violence, — of which opium, chloroform, 
and chloral hydrate are, in these days, the most familiar examples. In 
certain cases of extreme urgency it may be necessary to enlarge the ori- 
fice of the vagina by lateral incision of the perineum ; and, if we are 
certain that the child is dead, and it is making but slow progress under 
very violent uterine propulsion, we are justified in lessening the bulk of 
the head by the operation of craniotomy. In so far as the forceps is 
concerned — and the remark applies with still greater force to turning — 
we must not be astonished if any attempt at operative assistance should 
excite the organ to more violent contraction still, and thus defeat its own 
object. What constitutes morbid or excessive uterine action can of 
course only be learned by experience. 

The treatment of actual rupture, however desperate the circumstances 
may seem, calls for every possible attention, not only in the interest of 
the child — which may often be saved — but in that of the mother, who 
may, even in unpromising cases, rally from the effects of the injury, and 
ultimately recover. We must not, therefore, accept the dictum of Smel- 
lie, that the accident is an absolutely hopeless one. All the best au- 
thorities are agreed that a speedy removal of the child affords the mother 
the best chance even when, the child being dead, this is done without 
any reference whatever to its condition other than considered as a foreign 
body. If the head of the child is still in the pelvic cavity, and thus 
within reach, it may be possible, although very rarely, to grasp and 
deliver it by the forceps ; and, it need scarcely be said that, if this can 
easily be done, it ought to be preferred as the method which is at once 
easiest and safest. As, however, in a large proportion of such cases, 
rupture is associated with more or less of pelvic disproportion, the usual 
practice is to perforate, and then to extract by the crotchet or craniotomy 
forceps, after havini; evacuated the contents of the cranium. This ope- 
ration is, under such circumstances, attended with special difficulties, 
which may render its performance a matter of difficulty or impossibility. 
Instead of being, as in most other cases, firmly held in position by the 
uterus, the foetus is apt to pass upwards on the slightest pressure towards 
the abdominal cavity ; and, if the rupture be a transverse one, such 
pressure is apt to increase it; while, again, if a portion of the foetus has 



TREATMENT. 425 

already passed into the peritoneal cavity, the remainder may thus be 
propelled in the same direction. It has been recommended, therefore, 
in order to obviate these difficulties, to use the perforator so as to press 
the head back towards the hollow of the sacrum by directing the handles 
forwards as much as is possible in the direction of the sub-pubic angle. 
Success in any attempt such as this will be more probable if we avail 
ourselves of the aid of an assistant, whose duty it should be' to maintain 
the child in the position which it occupies, by sustained and judicious 
pressure exercised through the abdominal walls. 

If we succeed in this way in effecting delivery of the child, Ave may 
then encounter another, and probably a more serious difficulty, in the 
extraction of the placenta. This organ, in a large proportion of cases, 
Avill be found to have escaped through the gap in the uterine parietes 
into the abdominal cavity, and, if contraction has subsequently taken 
place to any considerable extent, the aperture may thus be so reduced 
that great difficulty will be encountered in any attempt to draw it down. 
Too much caution cannot here be observed with the view of av^oiding 
further laceration and extension of the wound. Were we to attempt to 
force the hand through the opening in order to seize the placenta, this 
would almost certainly occur. It is better, therefore, to use the cord as 
an extractor, and to pull the placenta towards the opening and then 
cautiously through it, and in this way complete the delivery. A prolapse 
or hernia of a portion of the intestine through the wound is by no means 
an unfrequent complication of such cases, and it is a matter of doubt in 
many instances whether we should or should not attempt to replace the 
protruding intestine. In so far as the risk of strangulation is concerned, 
this is a matter of trifling importance, for the usual situation and direc- 
tion of the rupture, and the relation which it bears to the uterine fibres, 
render it a very unlikely matter that strangulation should occur ; and, 
apart from the chance of a recurrence of the prolapse, it may fairly be 
doubted whether the risk of displacing the clots and again disturbing 
the wound will not do more harm than good — as recovery has taken place 
even when a considerable coil of intestine has passed through the wound 
and occupied the vagina. 

In a very considerable proportion of cases of rupture of the uterus, it 
is impossible to deliver by the natural channel, on account either of 
pelvic deformity, contraction of the os, or escape of the child into the 
abdominal cavity. In the first case, our course of procedure will depend 
upon the degree and extent of the deformity ; and, in the second, the 
rigidity may possibly be overcome by the use of chloroform, or even by 
incision of the tissues of the os, our object being, in every case in which 
the child remains in the uterine cavity, to deliver, if it be possible, per 
vias naturcdes. But, in the third case, when the child has escaped from 
the uterus, and lies among the intestines in the abdominal cavity, our 
treatment must be essentially different. So hopeless w^ere such cases at 
one time generally regarded, that some of the most eminent accoucheurs 
— Denman among others — recommended that we should not in any way 
interfere, but leave the case to nature, as it has happened that women, 
even under such desperate circumstances, have recovered, the child 
ultimately being discharged piecemeal by the ulcerative process, as in 



426 RUPTURE OF THE UTERUS. 

cases of extra-uterine pregnancy. In several cases in which rupture of 
the uterus and escape of the child into the peritoneal cavity had occurred, 
delivery has been effected and the woman saved by the operation of turn- 
ing, the hand being passed through the rupture, the feet of the child 
seized and brought down, and the delivery completed in the usual way. 
The fortunate result of these cases gave rise to a very general impression 
that this was the method of treatment most suitable for such cases ; but 
the gross results of the operation have turned out so unsatisfactory that a 
very general and growing belief now exists that, whatever may have 
been the result in rare and favorable instances, the chances of the woman 
are by this procedure rather diminished than increased. Dr. Barnes be- 
lieves, and with some reason, that the cases alluded to were chiefly 
examples of rupture of the vagina, the rent of which is not contractile, 
and it is certain that it would scarcely be possible to deliver in this way 
in an ordinary case, w^ithout displacing the clots, increasing the rent, 
and thus exposing the woman anew to the danger of increased hemor- 
rhage and redoubled shock. If it is to be performed at all, it seems to 
us to be applicable only to such cases as present a cervical rupture of 
considerable size, and in which the general condition of the woman is un- 
usually favorable. 

The statistics of Dr. Trask, and the experience of later years, have 
very much modified the views previously entertained by competent 
authorities on the subject of gastrotomy in those cases of uterine rupture 
in which the child is in the peritoneal cavity. The dangers of such a 
course are manifest. There is increased shock, and the special risk 
which attaches to all cases in which the cavity of the peritoneum is 
opened ; and, in addition to this, we may take into consideration the 
natural repugnance which is entertained by the patient's friends to such 
an operation, so long as another is in any way practicable. It must 
certainly be confessed that, in so far as it has been possible to institute 
a comparison between turning and gastrotomy in cases in which the child 
is outside of the uterus, the presumption is entirely in favor of the latter. 
The results of turning, and of removal through the rupture and the vulvo- 
uterine canal, are, according to Trask, as unfavorable to the mother as 
when we abandon the case absolutely to nature. But, in those in which 
the operation of gastrotomy has been preferred, the results have been 
much more favorable, about two-thirds of the cases collated by Trask 
having been saved. We must be very cautious, however, in admitting 
such figures as representing the true facts of the case, as we cannot but 
believe that many fatal cases are, for reasons which are sufficiently 
obvious, suppressed. This is the reason why here, as well as elsewhere 
in this work, comparative tabular statements are omitted as likely to lead 
to misapprehension and false hopes. The safety of the child is in all 
such cases a secondary matter ; but it may be admitted, as an element 
of the case for our consideration, that, where the operation of gastrotomy 
has been promptly performed, the child has occasionally been saved. On 
the whole evidence, then, w^e must pronounce in favor of gastrotomy 
when the child is in the peritoneal cavity, of turning when it has remained 
m the cavity of the uterus, and of the forceps or perforation where the 
head can be easily reached within the pelvis. 



GASTROTOMY. 427 

The operation of Gastrotomy is simply the first stage of what will 
afterwards be more particularly described as the Caesarean Section. A 
loncritudinal incision havino; been made in the middle line, below the urn- 
bilicus, Avith those antiseptic precautions which the modern operation of 
Ovariotomy has made familiar to us, the child is to be at once removed, 
along with the placenta and such clots as may be w^ithin reach. ^ The 
wound should then be closed in the usual Avay, and a full opiate admin- 
istered, while the patient is ordered to be kept in a state of perfect quiet, 
both of body and mind. Some difficulty may possibly arise, both before 
and after the operation, as to the use of stimulants. The condition of 
shock and general depression, and the state of the pulse may, on the one 
hand, indicate that we should not withhold them ; but, on the other, our 
apprehension of the dreaded though inevitable peritonitis is such, that we 
shrink from any treatment which might tend to aggravate the inflamma- 
tory action, upon the degree and extent of which the life of the patient 
will depend, more, perhaps, than upon anything else. It is, in fact, im- 
possible in this particular, to lay down rules for our guidance ; so that 
we must act, to the best of our judgment, as the exigencies and pecu- 
liarities of an individual case may seem to indicate ; but it w^ill probably 
be necessary, in most cases, to rally the patient in some degree from the 
shock which has attended the accident, before proceeding to perform the 
operation which we may have selected. 

In those cases in which rupture has occurred in the course of preg- 
nancy, the treatment wdll, in some measure, depend upon the stage of 
pregnancy. In so far as rupture in the early months is concerned, some- 
thing must be allowed for the difficulty of diagnosis, as it would be diffi- 
cult, in such a case, to know whether it was a rupture of the uterus, or 
of the cyst of an extra-uterine pregnancy. This distinction is not, how- 
ever, one of any great practical importance, as the treatment in the two 
cases is probably identical, and there seems no reason to doubt that, in 
this case, the best chance would be to leave all to nature, in the hope 
that, by the ordinary process of ulceration, the foetus may ultimately be 
discharged. When the rupture takes place in the later months of preg- 
nancy, the conditions are quite different, and the indications of treatment 
are more those of rupture during labor. If we are certain that the foetus 
has escaped from the uterus, there must be no hesitation here as to the 
advisability of gastrotomy. For, wdth an os firmly closed, it would be 
futile to attempt dilatation of it and the cervix as a preliminary to thrust- 
ing the hand through the uterus into the abdominal cavity, so that we 
cannot here even think of turning. Some have recommended, wdien the 
child is still within the uterus, a forced dilatation of the os, and even in- 
cision of the cervix, to be followed by turning ; but we very much ques- 
tion whether, even here, it would not be preferable to perform gastrotomy, 
and extract the child from the w^omb by enlarging the laceration, should 
this be necessary. Under circumstances such as these, many w^ould 
probably prefer trusting to nature. 

' When tlie incision is made in the region under the ribs, the operation is called 
Laparotomy. 



428 DEFORMITIES OF THE PELVIS 



CHAPTEE XXyil. 

DEFORMITIES OF THE PELVIS. 

Importance of the Subject. — Classification of Deformities. — Causes: Diseases 
affecting the Pelvis : Rachitis: Malacosteon. — Rickets and Malacosteon con- 
trasted: Nature of the Brim Deformity characteristic of each. — Possihilitij of 
yielding in a Malacosteon Pelvis. — The Ohliquely- Distorted Pelvis.— De- 
formities of the Cavity : Flattening of the Sacrum: Funnel-shaped Pelvis. — 
Distortion of the Outlet : Approximation of the Tuherosities of the Ischia : 
Projection Forivards of the Coccyx: Anchylosis of the Sacro-coccygeal Ar- 
ticulation. — Masculine Type of Pelvis. — Infantile Type. — Effect of Muscular 
Action in Producing Pelvic Distortion. — Spondylolisthesis. — Pelvis ALqua- 
biliter-justo-Major, and justo-Minor. — Obstruction from Exostosis, Osteo- 
sarcoma, and other Tumors: from Fractures of the Pelvis^ and Morbus 
Coxarius. — Symptoms : Measurements of the Pelvis: Pelvimeters : Examina- 
tion by the Fingers. — Effects of Distortion. — Difference betiveen ^^ Impaction" 
and ^^ Arrest." — Treatment. — Prevention. — Circumstances lohich call for the 
Forceps, Turning, Craniotomy. — Use of the Forceps in Deformed Pelvis. — 
Coisarean Section. 

Before passing to the more particular consideration of Operative 
Midwifery, it is proper that we should in the first instance turn our 
attention to the important subject of Pelvic Deformity ; upon which con- 
dition a very large proportion of all midwifery operations depends. The 
first point which may be regarded as essential to the mastery of this 
important subject is, beyond all doubt, a correct appreciation of the nor- 
mal standard, or, in other words, an accurate knowledge of the anatomy 
of the female pelvis. Upon this also, as we have already seen, hangs 
the whole theory of the mechanism of parturition ; but, so soon as de- 
formity of any kind disturbs the relations which subsists between the 
various pelvic diameters, it converts the harmonious whole of a normal 
pelvis into discordant elements, to which it is impossible to adapt such 
laws as under ordinary circumstances guide our action. If the art of 
obstetrics stopped short here, it would have little claim indeed to the 
dignity of a science. No point, however, within the area of our subject 
has attracted more of the attention of those to whose genius and industry 
we are under the deepest obligation ; and the light which their expe- 
rience and investigation has thrown on it, enables us in these days to look 
upon the deviations from the normal standard to which we have alluded 
with more of confidence than apprehension. For the occurrence of diffi- 
culties more or less formidable, then, we must be prepared; and nothing 
will suffice for an intelligent and satisfactory appreciation of these, short 
of an intimate knowledge of the causes upon which pelvic deformities 



CAUSES. 429 

depend, and the practical contingencies which thej involve. Many 
attempts have, from time to tiDie, been made to classify and reduce these 
morbid conditions into genera and species, but they have been attended 
for the most part, in so far as practical results are concerned, with but 
indifferent success. Many of the best authorities, whom we shall in this 
matter attempt to follow, abandoning any such scheme, have therefore 
attached to the conventional phrase, "pelvic deformity*" a signification 
'somewhat beyond what its etymology would seem to imply, so as to in- 
clude, as we shall see, certain cases in which no deformity in the strict 
sense of the terra exists, and yet in which the mechanical requirements 
of natural labor cannot possibly be assumed to exist. Many of the famil- 
iar terms arising from the systems of classification alluded to will be 
employed in the sequel, but only so far as may be necessary to meet the 
exigencies of formal description. 

The Causes of pelvic distortion are various, but by far the most im- 
portant are Rachitis and Malacosteon. Although closely allied in respect 
of the morbid conditions upon which they depend, these diseases are, 
nevertheless, to be carefully distinguished in regard to the difficulties 
which they engender, and the effects which they produce on the course 
of parturition otherwise natural. An elaborate consideration of the pa- 
thological conditions, symptoms, and progress of these diseases is alto- 
gether foreign to a work such as this ; but there are certain points of 
similarity, and still more of contrast between the two, a knowledge of 
which is essential to a correct appreciation of the subject in all its bear- 
ings, and to which, therefore, it is necessary that we should at this place 
briefly advert. One of the most essential, and, in regard to our subject, 
one of the most important points of distinction between rachitis and mala- 
costeon is, that Avhile the former is a disease of childhood, the latter is a 
disease of adult life ; and it is only necessary to compare the form, and 
degree of inclination of the pelvis of an infant (see Fig. 17) with that of 
the adult, to see that the effect which must inevitably be produced in the 
two cases, by a yielding of the osseous structures, can only be attended 
with results, as regards the measurements and form of the pelvis, which 
of themselves would suffice to establish a marked distinction. Such dif- 
ferences in form as result from the operation of this cause — to which we 
shall more particularly refer — are by no means the only features which 
fix our attention in this direction. 

Rachitis or Rickets is, as we have said, a disease of infancy and 
childhood, which very rarely comes on after the age of puberty. It is 
attended from the first by a marked cachexia, which the best authorities 
seem to regard as closely allied to that of scrofula ; but the first symp- 
tom which clearly points to the nature of the case, is the yielding of the 
bones, which soon gives rise to more or less of deformity in those parts 
of the skeleton which have most to do with the support of the body — 
namely, the spine, pelvis, and lower limbs. The chief morbid alteration 
upon which these morbid phenomena depend is a diminution of the earthy 
constituents of the bones ; but the change goes much further than this, 
and involves corresponding alterations in the animal portion, and thinning 
of the dense or laminated texture, with a consequent predominance of 
the cancellated structure, and the formation of certain new and semi-solid 



430 DEFORMITIES OF THE PELVIS. 

products. Some bones suffer more than others, and even some parts of 
the same bone may be affected to a comparatively greater extent. The 
amount of deformity which is thus produced will obviously depend, in a 
great measure, upon the extent to which the disease exists, and the con- 
tinuance of the morbid conditions referred to ; but it is generally observed 
that the deformity is not confined to any particular part of the osseous 
framework, but affects it generally, the more conspicuous symptoms bein^ 
spinal curvature and flexion of the bones of the leg. With the distortion 
in these regions, or in the thoracic cavity, we have here nothing par- 
ticular to do ; but, as regards the pelvis, there is almost always more or 
less deformity caused by the weight of the trunk, which is thrown upon 
the bones of the pelvis from the spinal column through the sacrum. An- 
other important point of special interest to us is that rachitis is usually 
accompanied with arrest of growth, which, although most marked in the 
lower limbs, and thus imparting dwarfishness to the frame, is also to be 
noticed in the pelvis, which is often, on this account, abnormal in respect 
of size as well as of distortion. We shall not further follow the symp- 
toms and progress of rickets. It will suffice to observe that the general 
tendency is towards recovery, which is first indicated by an amendment 
of the general health, disappearance of the cachectic symptoms, and 
(with more inclination for muscular action) a steady amelioration in the 
morbid condition of the bones, in which the. phosphatic deficiency is 
gradually improved. Ultimately, the health and strength are perma- 
nently restored, but the period of restoration merely fixes the bones for 
life in the distorted position. Judicious treatment during the period of 
convalescence no doubt often modifies the amount of ultimate deformity ; 
but such treatment is usually directed to the spine and lower limbs, while 
the pelvis comes in for a much smaller share of attention. The accou- 
cheur should always remember that the existence of spinal curvature is 
not in itself evidence of antecedent rickets, a consideration which may 
be of importance, chiefly with reference to prognosis. 

Malacosteon, or Osteomalacia, is much rarer than the preceding, and 
is essentially a disease of adult life. The process of ossification has, we 
may suppose, been satisfactorily accomplished ; and then come on, for 
the first time, the morbid conditions upon which the distortion depends. 
Although in this case, as in that of rickets, the most usual occurrence is 
a disproportion between the earthy and animal constituents of the bones, 
their whole structure suffers considerable alteration. It is more fre- 
quently observed in females than in males ; while in rickets there does 
not seem to be any preference for sex. The general symptoms which 
accompany malacosteon are, from an early period of the case, very grave. 
It usually runs a rapid course, manifests no tendency to repair, defies all 
attempts at treatment, and, sooner or later, has a fatal result. The dis- 
ease may aff"ect the whole skeleton, or may be limited to several bones, 
or to one ; and it would appear that the pelvis at least rarely escapes. 
It would also seem to involve the entire texture of the affected bones more 
equably than rickets. Softening of the bones is the usual characteristic, 
but it may occasionally be attended with brittleness, to which the term 
Fragilitas Ossium has been applied. Molities Ossium is not, therefore, 
to be accepted as absolutely synonymous with Malacosteon. 



MALACOSTEON. 431 

In contrasting these two morbid conditions, the first point of importance 
to the accoucheur is that, in rickets, we are dealing, not with disease, 
but with the effects of disease, the pelvis being, in fact, often more dense 
in structure than if it never had occurred ; while, in malacosteon, we have 
actually existing and progressive disease. From this arises a practical 
point, which may be noticed here, although with no attention to exag- 
gerate its importance. Tnis is the possibility of some yielding of the 
bones of the diseased pelvis in the latter aifection, so as to admit of par- 
turition, or of operative assistance which would otherwise be unavailable. 
A case of this kind is given by Osiander, who, being about to perform 
the C?esarean section in a malacosteon pelvis, made a final attempt by the 
hand — an attempt which, owing to such relaxation as is here described, 
actually succeeded. 

The condition and circumstances of the patient at the period of the 
occurrence are such as to exercise a very important influence on the nature 
of the distortion. Rickets, in most cases, comes on before the child has 
begun to walk, or, if it has walked, the nature of the disease renders 
this no longer possible, so that the most likely mechanism of distortion 
in these instances is a force acting through the spinal column downwards 
upon a yielding pelvis. In malacosteon, on the other hand, the patient 
may walk or stand during the process of softening and the weight of the 
whole trunk is thus transmitted to the heads of the thigh bones. This 
diiference in the nature of the forces or mechanism of pelvic deformity 
is well shown in the characteristic features of rachitic and malacosteon 
pelves. In a typical case of the former variety there is, as shown in Fig. 
140, a marked projection forwards of the sacrum by the operation of the 

Fis. 140. 




Rachitic Pelvis. 

cause above alluded to. This is by far the most frequent of all the 
varieties of deformity which have been described. It may (as shown in 
the figure) or may not be associated with flattening of the anterior wall, 
and projection backwards of the symphysis pubis, but the efi"ect, in every 
case, is a more or less marked diminution of the conjugate diameter of 
the brim. Diff'erent varieties of this distortion have been described as 
"masculine," "heart-shaped," and " figure-of-eight" deformities of the 
brim ; all of which are, as will be observed, mere modifications of the 
same condition, and all of which partake of the character of elliptical 
distortion. In malacosteon again, the general characteristic of the de- 



432 



DEFORMITIES OF THE PELVIS. 



formity is angular^ and is due to antero-lateral displacement of the pelvic 
walls by pressure exercised upon the acetabula. This is indicated in a 
typical form by the rostrated variety shown in Fig. 141, where the con- 
jugate diameter is increased at the expense of the transverse and oblique. 

Fig. 141. 




Malacosteou Pelvis. 

Endless varieties and combinations of these two may occur, so that the 
distinction between a rickety and a malacosteon pelvis is only to be 
accepted with the qualification that some cases partake of the character- 
istics of each. Thus, in the case of Isabel Redman, operated upon by 

Fig. 142. 




Isabel Redman's Case, 



Dr. Hall, the conjugate and oblique diameters were both involved, con- 
stituting a very serious modification of distortion in this situation. These 
are, of course, mere illustrations of possible variations, which might be 
infinitely multiplied ; but it is to be remembered that a considerable 
number of cases have been met with in which an undoubtedly rickety 
pelvis presented all the more prominent characteristics of malacosteon 
deformity. 

In so far as the true malacosteon pelvis is concerned, it has been well 



VAKIETIE3. 483 

observed by Stanley that there is no diminution in the actual circumfer- 
ential measurement of the brim ; and that the bones are of their natural 
bulk and proportion, so that, " if their various doublings were unfolded," 
the pelvis would be restored to its normal dimensions and form. In 
rickets, however, this does not usually apply, owing, as has already been 
observed, to the partial arrest of development which obtains during the 
course of the disease. 

In the majority of cases of pelvic deformity, there is a want of sym- 
metry, one side being affected to a greater extent than the other. This 
is due to a variety of causes, probably one of the most important being 
the alteration of the centre of gravity in consequence of spinal curvature. 
A very peculiar and extreme variety of this land is that which was so 
fully described by Naegele in his memoir on the subject as the '■'• loelvis 
ohliqiihovata^^ or Obliquely Distorted Pelvis. In these very interesting 
cases, there is anchylosis of the sacro-iliac articulation on the affected 
side, which is flattened and its development arrested, as is shown in Fig. 
143. Half of the sacrum is imperfectly developed, and the oblique dis- 

Ficr. 143. 




Obliquely Distorted Pelvis. 

tortion is such that the whole of that bone is carried towards the affected 
side, while the sacro-iliac synchondrosis of the sound side is brought 
nearly opposite to the pubic symphysis. 

Deformities of the cavity of the pelvis may either be associated with 
some of those above described, or may exist independently. One of the 
best known of these, and which is by no means an uncommon cause of 
impaction of the head within the cavity, is " flattening" of the sacrum as 
here shown (Fig. 144). The normal recession of that bone being 
wanting, the conjugate diameter of the cavity is proportionately cur- 
tailed, and the movement of rotation rendered impossible. 

In other cases, the diameters of the pelvis are diminished from above 

downwards, so as to constitute what has been designated and described 

as the " funnel-shaped" pelvis. An example of this, from an original 

drawing of such a case, is shown in Fig. 145, in which the gradual 

28 



434 



DEFORMITIES OF THE PELVIS 



approximation of the ischial planes is greatlj increased, and the flatten- 
ing of the sacrum contributes to the reduction of the conjugate diameter. 

Sometimes the curve of the sacrum 
Fig. 144. is too great or too abrupt, as in 

the case represented in Fig. 146. 
This, however, might perhaps be 
supposed to come more within the 
category of distortion of the out- 
let, although it may, we appre- 
hend, be fairly considered as con- 
tributing to both. 

Distortion of the outlet is neces- 
sarily involved in many of the va- 
rieties which have been described. 
The general effects produced in 
malacosteon are, then, a narrowing 
of the transverse diameter, chiefly 
by approximation of the acetabula. 
This implies, as a reference to 
Fig. 141 will more clearly show, 
a diminution of the corresponding diameters of the cavity and outlet, 
which brings the tuberosities of the ischia nearer to each other, and 
thus reduces the sub-pubic angle, so that the head must descend further 
in the direction of the perineum, before it can pass under the sub-pubic 
arch. And, in like manner, a diminution of the conjugate diameter at 
the outlet will materially impede the birth of the head. An abrupt 
curve of the sacrum, as shown in Fig. 146, will have this effect, and if 




Flattening of the Sacrum. 



Fig. 145. 



Fiff. 146. 




Funnel-shaped Pelvis. 



Exaggerated Sacral Curvature. 



there should be, as has been observed, anchylosis of the sacro-coccygeal 
articulation, the difficulties of the case will thereby be materially in- 
creased. When the deformity is confined to this part of the pelvis, it 



VARIETIES. 435 

has been observed that approximation of the ischial tuberosities is quite 
as frequent as conjugate contraction.^ 

The masculine type of pelvis has already been mentioned in reference 
to the deformities which exist at the brim. An extension of this to the 
cavity and outlet constitutes a very serious impediment to labor. In 
such cases, we may have the bones of the pelvis thicker, heavier, and 
more marked with muscular attachments, the cavity deeper — as is more 
particularly shown by the greater depth of the pubic symphysis, — and 
the sub-pubic angle rendered more acute by an approximation of the 
ischial tuberosities. Or, again, we may have an infantile type of pelvis, 
in which, from arrest of development, with or without rickets in other 
parts, the inclination of the brim is greater, and the transverse diameter 
relatively less than is normal, while the whole pelvis is smaller than it 
should be. 

It is a fact familiar to every surgeon, that the action of the muscles 
plays a most important part in producing distortion of a rickety skeleton ; 
but it would appear that this cause of pelvic deformity has not received 
anything like general attention at the hands of obstetric writers. The 
following observations on this point are borrowed from Dr. Murphy: " In 
the motions of the body, there are two sets of muscles connected with the 
pelvis to be considered, each having a distinct office to perform.* One 
set, passing anteriorly and posteriorly, between the pelvis and the thigh 
bones, keeps the pelvis fixed to its position; these, therefore, would act 
very powerfully in distorting the softened bone to which they are attached, 
but would manifestly produce a much greater effect when the body is 
upright and the pelvis is made a centre of motion, as in the adult 
pelvis, than when the body is bent forwards, and moves less upon the 
pelvis, as in the child. Such we find to be the case : the lower portion 
of the sacrum and the coccyx is bent, nearly at a right angle, by the 
great gluteal and pyramidal muscles, and close up the outlet. Ante- 
riorly, the effect is not so apparent in the adult pelvis, because it is 
counteracted by the acetabula and ischio-pubic rami being pressed in 
towards the centre ; but still the edges of these rami are more everted, 
and the pubic arch itself, immediately beneath the symphysis, is wider 
than it ought to be. The other set of muscles are those that maintain 
the body in its erect position ; posteriorly, the dorsal ; and, anteriorly, 
the abdominal muscles. The tendency of the former is to draw the 
sacrum towards the spine, and thus to increase the projection of the 
promontory ; the effect of the latter is to draw the ilium more upright, 
and to render it more irregular. The action of these muscles will there- 
fore explain the character of some of the distortions in the adult pelvis. 
In the infant pelvis, their influence is modified by the altered position of 
the body. In this case, the weight from above presses down upon the 
thigh-bones, and tends to separate them from each other ; the muscles, 
therefore, passing between them and the pelvis, will draw outwards that 
portion of the pelvis to which they are attached ; hence the ischio-pubic 

1 For an exliaustive account of tlie difference between malacosteon and rickety 
pelves, embodying the researches of Meyer of Zurich, see an article by Dr. Matthews 
Duncan in the Edinburgh Medical Journal for April, 1856. 



436 DEFORMITIES OF THE PELVIS. 

rami are more separated, and the tubera of the ischia more apart than 
natural ; but the distance of the thigh-bones being increased, the coccyx 
can still be drawn forwards by the muscles attached to it ; consequently 
the outlet is much more open than it ought to be, and the abruptly-curved 
sacrum becomes the only impediment to the escape of the head." 

It will be understood that the varieties of pelvic deformity above de- 
scribed are far from embracing all that might be adduced, as our object 
has been to avoid complication by simplifying the subject as far as is con- 
sistent with a correct appreciation of the facts which may be supposed 
to bear upon practice. Some of the rarer deformities are figured in 
Moreau's Atlas. There are still, however, one or two conditions which, 
although not strictly pelvic deformities, are very properly considered 
along with them. Among these Ave may first mention deformity due to 
disease of the lower portion of the spinal column, in which curvature, or 
other displacement of the bones, may prove as effectual a bar to natural 
delivery as the more common varieties of deformity at the brim. Of this 
nature is the affection which has been described under the name of Spon- 
dylolysthesis, when the last lumbar vertebra slips downwards and forwards, 
and directly encroaches on the conjugate of the brim. 

Nor can we omit to mention two other varieties of peculiarity in con- 
formation, in each of Avhich the shape of the pelvis, and relative meas- 
urements of its parts, are perfectly normal. The former of these, which 
has been termed the pelvis cequahiliter-jiisto-ynajor, implies a pelvis Avhich 
is symmetrically increased in all its diameters. Although such a con- 
formation as this must necessarily act by facilitating labor, by the com- 
parative ease with which it admits of the passage of the child, it is not 
to be regarded as a favorable condition. On the contrary, precipitate 
labor is always, and with good reason, looked upon with apprehension, as 
experience teaches us that, when moderate and normal resistance on the 
part of the pelvic walls is wanting, violent and rapid dilatation of the 
soft textures of the canal necessarily takes place, to the danger of their 
integrity at any part from the os uteri to the vulva ; and there are, in 
addition to this, other dangers, which will afterwards be more particularly 
described. The only advantage which may accrue from such a pelvis 
occurs, according to Churchill, in face presentations. To this we may 
perhaps add occipito-posterior positions of the cranium, and, in the ab- 
sence of all assistance, transverse presentations, as it would naturally 
favor spontaneous expulsion or evolution. The pelvis cequahiliter-justo- 
minor — the other variety referred to — is the converse of this. We have 
here also a perfectly-shaped pelvis ; but all the diameters are less than 
usual, so that a special impediment must in every such case exist, in a 
degree proportionate to the extent of the symmetrical deformity. What 
makes this a condition more unfavorable than we might at first suppose, 
is the absence of any possible compensation in one direction for a de- 
formity existing in another. We thus find that the moulding process is 
of much less avail here than where, for example, we have a moderate 
degree of conjugate contraction, with an ample measurement in the trans- 
verse, in which latter direction the head may, by compression, elongate 
itself, and thus, by changing its shape, pass the obstacle, after a certain 
amount of delay. 



VARIETIES. 



437 




We may here consider the effect which is produced by certain surgical 
diseases or accidents which may prove impediments, more or less insu- 
perable, to normal parturition. These are in their nature various, and, 
in their extent, offer every variety from a slight encroachment upon a 
single diameter to complete blocking up of the true pelvis. Osteosar- 
coma and Exostosis are two of the most 

important of these affections, and may Fig. 147. 

constitute, if of any size, an impedi- 
ment which renders delivery by the 
natural channel quite impossible. These 
tumors may take their origin from any 
part of the osseous tissue of the pelvis ; 
but the situation from which they most 
frequently spring is the upper third of 
the sacrum, encroaching therefore upon 
the brim and cavity by spreading from 
this centre. Care must be taken, by 
examination through the vagina, and, 
if necessary, through the rectum, not 
to mistake these for abnormal contrac- 
tion of the brim, due to projection of 
the sacral promontory. This is an 
error which has been committed, and 
wdiich would probably be in most cases Peivic Exostosis. 

avoided by external measurement of the 

pelvis ; and, if it should, in the course of such an examination, be dis- 
covered that the measurements in question were normal in extent, the 
presumption of exostosis would be increased. Tne absolute hopelessness, 
in the case of exostosis of large size, of delivering by the vagina, will 
appear by a reference to this familiar figure. 

Cancerous disease of the pelvic bones, resulting in the development of 
tumors of greater or less consistency, may be a serious mechanical im- 
pediment to the course of labor, besides being a condition which, apart 
from this, involves the life of the mother. These may spring from any 
part of the pelvis, and will probably develop in the direction in which 
there is least resistance, so that, if they have their origin in the inner 
surface, they can scarcely fail seriously to reduce the diameters of the 
pelvis in the same manner as the benign tumors previously described. 

The projection from certain portions of the pelvis of osseous spicula 
was made the subject of very painstaking investigation by Kilian, who 
found that a common situation of such spicula is at the margins of the 
various symphyses. It is not difficult to foresee the effect of such sharp 
thorn-like projections if they should chance to spring from the sacro-iliac 
synchondrosis, or from any other part of the brim of the pelvis ; and, in- 
deed, in such cases — which are fortunately very rare — scarcely anything 
could be looked for but laceration of the uterus and possible rupture. It 
would appear to be a general belief, that bony growths from the pelvis 
are in some way associated with the gout}^ or rheumatic diathesis. 
Partial ossification of the sacro-sciatic ligaments has been sometimes ob- 
served, and, when this takes place, the peculiarity would, no doubt, be 



438 DEFORMITIES OF THE PELVIS. 

suggestive of the natural condition in some of the lower animals. From 
these, from the other ligamentous structures, and from the periosteum, 
tumors of the fibrous or fibro-sarcomatous variety may spring, which, 
when constituting an apparent deformity in the pelvis, have sometimes 
been successfully removed in the course of labor. Any attempt at the 
removal of the purely bony tumors is out of the question, but cases have 
occurred in which the texture of these tumors was so loose, and so 
entirely composed of weak cancellated structure, as to admit of being 
crushed or broken down, either by the foetal head or the manipulations 
of the accoucheur. 

Fractures of the pelvis are occasional causes of pelvic deformity — 
either from the union of the fractured bones in a distorted position, or 
from the irregular development of callus in the direction of the pelvic 
cavity, the diameters being thereby reduced. Projections of this kind 
have been observed, in which the pelvic diameters involved were reduced 
to the extent of one and even two inches. Very considerable deformity 
of the pelvis may also be the result of Morbus Coxarius, which has gone 
on to dislocation and anchylosis ; or of fracture or dislocation of the head 
of the bone — the effect being due, in such cases, to the distorted condi- 
tion of the limb acting, in all probability, on a pelvis which is morbidly 
softened, or at least in a constitution which is impaired. 

Symptoms. — These may, to a great extent, be inferred from what has 
been said in reference to the causes from which pelvic deformities are 
believed to arise. In marked cases, involving considerable deformity — 
such as may be due to Rachitis — the general distortion of the skeleton 
will point to the pelvis as a part of the solid framework of the body 
which can hardly be expected to have escaped. But an obvious rickety 
condition of the skeleton is no evidence Avhatever, either of the degree or 
of the nature of the deformity. It is necessary, therefore, in such in- 
stances, if we desire to gain an accurate knowledge of the nature of the 
case, to observe with great care the actual pelvic measurements, both 
externally and internally. The conjugate diameter is that which in most 
instances we are anxious to determine, and, in so far as this may be in- 
ferred from measurement in the living subject, it may be approximately 
ascertained by the use of Baudelocque's callipers, which are here shown. 
By this, and making a deduction of about three inches for the soft parts, 
the measurement from the posterior sacral spines to the anterior surface 
of the pubic symphysis should be about seven inches. Such a method 
of examination as this is so manifestly open to the operation of disturb- 
ing causes, that little reliance can be placed on inferences which are 
drawn from it alone, so that various instruments have been devised, and 
a great amount of mechanical ingenuity has been expended, on the con- 
struction of an internal pelvimeter. One of the earliest instruments of 
this kind was the pelvimeter of Coutouly, which closely resembles in its 
form the rule used by shoemakers in measuring the length of the foot, 
and consists of two parts, one of which slides in a groove in the other. 
A limb projects from the extremity of each of these at right angles to 
it. The instrument is introduced beneath the arch of the pubis, and 
pushed onwards until the extremity touches the sacral promontory. It 
is held in this position, and the pubic portion is then slid forwards until 



PELVIMETRY. 



439 



it touches the posterior surface of the pubic symphysis. The distance of 
the sacrum from the pubic bones is indicated by the extent to which the 

Fig. 148. 




Baiidelocque's Callipers, and Coutouly's Pelvimeter. 

anterior portion is thus drawn out, which is read off in inches marked on 
the stem. The total length of this instrument, which is also represented 
in Fig. 148, is about eleven inches. 

An immense number of pelvimeters have since then been invented. 
That which is here figured, as designed by Dr. Lumley Earle, is proba- 
bly one of the best and simplest : it is to be introduced into the va'gina 
with the shorter of the two limbs turned towards the pubis ; and, on the 
extremity reaching the level of the brim, as ascertained by the finger, 
along which it is carefully guided, the handles are pressed together, and 
their divergence read off on the scale which is between them. The ob- 
jection to all such internal instruments is, that they are difficult of appli- 
cation so as to insure accurate results, and besides not altogether safe, 
unless used with great caution. Coutouly's is, for reasons which are 
quite obvious, inapplicable to cases in which the woman is in labor, and, 
indeed, to cases of pregnancy, so that in the very instance in which we 
are most anxious for exact information, it is practically valueless. Dr. 



440 



DEFORMITIES OF THE PELVIS, 



Fio-. 149, 



Earle's is, no doubt, from this point of view, to be preferred. But even 
when, in the absence of pregnancy, we may wish to ascertain the condi- 
tion of the pelvis, it is by no means an easy matter to use either the one 
or the other. 

All such contrivances, indeed, as have hitherto been invented, are 

open to the objections which have just been 
stated. Many of the best authorities have, 
on this account, absolutely discarded them, 
and prefer the simpler method of investi- 
gation by the finger. The various methods 
by means of which Ave may thus gain infor- 
mation have been admirably described and 
illustrated by Dr. Ramsbotham. "Three 
methods," he says, "are practised: one 
is, by the introduction of the first finger of 
the right hand within the vagina, so that 
the point should be carried up to, and 
touch the sacral promontory, while the root 
of the finger is applied exactly under the 
symphysis pubis, at the upper part of the 
arch. It must be evident that this mode 
of inquiry will be of no avail unless the 
pelvis be greatly distorted — considerably 
under three inches, indeed, in the conju- 
gate diameter. For the ordinary length 
of the index finger along its inner edge is 
less than three inches ; and as the oblique 
line from the promontory to the apex of 
the pubic archi exceeds the direct line 
across, so if there be more than the space 
just mentioned, the finger would not be 
able to reach the projection, and we should 
consequently be in utter ignorance what 
amount of room existed. If the pelvis be 
very small, the sacral promontory can be 
felt with ease; but, even in that case, the 
dimension of the direct conjugate diameter 
is not afforded, but the length of the ob- 
lique line is given; and it is not always possible to calculate the diifer- 
encQ between these two lines accurately. 

" Another mode which has been recommended is the introduction of 
the whole left hand within the pelvis, with the outside or point of the 
little finger touching the inner surface of the symphysis pubis, and the 
first finger placed against the promontory of the sacrum. As every man 
is aware what his hand measures across, it is supposed he will be able to 
ascertain the transverse (conjugate ?) diameter of the pelvis. Thus, 
presuming the hand to be two inches and three quarters wide, which is 
the common average about the centre of the fingers, if when placed edge- 
w^ays, it just fits the brim, the examiner will know that the space is 
within three inches. Again, if he can only introduce three fingers in- 




Lumley Earle's Pelvimeter. 



MANUAL PELVIMETRY. 



441 



stead of four, he will know that the pelvis does not measure two inches, 
and probably not so much ; and, if he can only pass up two fingers, 
closed together, he will be assured that there is not more than an inch 
and three-eighths. But, on the contrary, if, in introducing the whole 
hand, he be compelled to spread his fingers widely before he can touch 
the sacral promontory, he will then be certain that the space is more than 
three inches, probably four, 
or near it. But it is not 
always easy to follow this 
mode of inquiry, because the 
child's head is generally pro- 
truded somewhat into the 
pelvis, even when the brim 
is contracted; and we could 
not carry the hand up in this 
manner, and make the accu- 
rate examination which we 
require to do, unless the brim 
as well as the cavity were 
perfectly free and unoccu- 
pied. It might, perhaps, be 
employed with advantage, 
provided the deformity was 
excessive. 

" The third method I con- 
sider the best, and is the one 
I myself adopt. Two fingers 
of the left hand are to be 
carried within the vagina ; 
the extremity of the first fin- 
ger is to be placed exactly 
behind the symphysis pubis, 
and the tip of the second 
against the sacral promon- 
tory. (See Fig. 150.) By 
stretchino; the fino;ers in this 
way, we shall have little dif- 
ficulty in reaching the promontory of the sacrum, even when the pelvis is 
of ordinary dimensions; and by withdrawing them in the same position, 
we may measure off the distance between their extremities on the first 
finger of the right hand, or on a scale of inches, or with the limbs of a 
pair of compasses ; and, consequently, we arrive at an accurate knowledge 
of the great dimensions of the pelvic brim. The laxity of the vagina, 
and other soft structures, which almost invariably attends the process of 
labor, w^ill permit the fingers to be withdrawn while extended ; and if the 
examiner uses sufiicient care, they may be kept perfectly steady until 
the space which they embrace be ascertained. This mode of proceeding 
possesses a great advantage over the other two, inasmuch as we are able 
equally well to make our examination, whether the head be occupying a 
part of the pelvic cavity, or whether it be still detained quite above the 




Mauual Pelvimetry. (Ramsbotham.) 



442 DEFORMITIES OF THE PELVIS. 

brim ; for, even if it be engaged in the vagina, one finger may be passed 
anterior to, and the other behind it, with comparative ease." 

It is only, however, after considerable experience that such arbitrary 
methods of examination are of much value in diagnosis. Very marked 
deformity is usually recognized easily enough, but the more important 
question of the degree or amount of distortion is not so readily solved, 
and will always require most careful and exact observation. It is upon 
the latter, indeed, that the most important practical considerations hinge ; 
and upon the result of such an investigation, be it right or wrong, will 
depend whether in a given case, we determine in favor of operation by 
the forceps, turning, craniotomy, or the Csesarean section. The actual 
measurements which relate to these operations will be more particularly 
considered in the chapters which follow. 

The effects, direct and indirect, of pelvic deformity, are often very 
serious, and are usually to be observed, as might be anticipated, in ne- 
glected or mismanaged cases. A common result of long-continued pres- 
sure upon the tissues of the os and cervix is sloughing of these parts, 
attended with irritative fever, and general symptoms even more severe 
than this. The destruction of tissue v/hich is involved in this process 
may result in fistulous openings into the bladder or rectum, requiring sub- 
sequent operative procedure for their cure. Pelvic deformity is, as is 
universally admitted, a frequent cause of rupture of the uterus, sometimes 
from actual bursting, due to the violence of the pains, and, in other cases, 
from pressure of the walls of the uterus against some part of the brim of 
the pelvis. The great amount of pressure which is exercised in these 
cases is occasionally shown in a significant manner by the moulding and 
alteration in shape of the child's head. This sometimes presents an 
indentation of the parietal bone from the pressure of a projecting sacral 
promontory ; and, under the influence of the same cause, even fracture 
of the parietal bone has taken place. Another marked effect, produced 
by the arrest of the child's head or other presenting part, is the forma- 
tion of a caput succedaneum of very unusual size, in the observation of 
which a serious error may arise. The formation of this swelling is a 
process of gradual development in the direction of the vagina, and not of 
sudden growth : it may, therefore, happen, that an inexperienced person, 
who feels that the actual surface of the scalp approaches nearer and 
nearer to the finger, may take this as evidence of a gradual advance of 
the head, the passage of which may nevertheless be absolutely barred. 
If, in consequence of this or any similar error in judgment, the case is 
left too long to nature, the powers of the woman progressively decline, 
and she soon reaches a condition in which we act at a great disadvan- 
tage, and even with much apprehension as to the ultimate result. 

In cases of extreme deformity, the head does not even engage in the 
brim, so that the effect of the ordinary expulsive efforts is simply to 
pinch or compress the lower segment of the uterus against the pelvic 
walls, while the os is being slowly dilated by the bag of waters. When 
the deformity is confined to the brim, and the promontory is not within 
reach of the finger, the nature of such a case is probably overlooked at 
first, as the examiner may conclude, from a simple exploration of the 
vagina by one finger, that everything is quite normal and that the pre- 



TREATMENT. 443 

sentlng part will descend presently. In other instances, the obstruction 
being less in degree, the vault of the cranium passes the plane of the 
brim, and the head is only arrested when its principal diameters come 
to be involved ; and, in a third class of cases, the obstacle being in the 
cavity or even at the outlet, labor goes on quite naturally until the head 
reaches the particular plane at which the obstruction exists. 

There is one point, in reference to these cases, in which it is of much 
importance that we should ascertain the relative condition of the parts 
involved ; this is best expressed by drawing a careful distinction between 
the terms " impaction" and " arrest," which are sometimes used some- 
what loosely, as if the expressions were synonymous. By impaction, we 
should imply only such a condition of the head as consists in its being 
actually jammed in the pelvis. In such a case, not only does the head 
make no advance with the pains, but it does not recede during the 
interval, so that it is immovable in both directions. In a case in Avhich 
the head is only arrested, however, there may be an equal impossibility 
as regards the advance of the head ; but its recession during the interval 
between the pains shows that the period of impaction has not yet been 
reached — a point which may be of very considerable importance in regard 
to the probable success or failure of a given operation. 

Treatment. — The management of cases of pelvic deformity w411 be 
treated of in detail, Avhen, in the subsequent chapters, the various opera- 
tions are considered, the necessity for which arises in a great measure 
from this particular cause. The accoucheur is occasionally consulted in 
reference to such cases, at a time when the dangers of pelvic distortion 
may be averted or modified. If it be a question as to marriage, it may 
be a very difficult as well as a delicate matter to decide, in a rachitic 
patient, between celibacy and the possible dangers of pregnancy ; but, if 
the case should be put before us, we must simply advise according to the 
facts revealed in the course of a thorough examination, when, if there 
should be evidence of such distortion as would probably call for the 
operation of craniotomy, it will be proper to withhold our sanction to a 
marriage under such circumstances. Another possible case, in which 
prevention rather than treatment may require consideration, is when the 
woman is pregnant, and the evidence of extreme distortion is clear ; or 
when, in previous pregnancies, labor has only been terminated by the 
sacrifice of the child. In both of these instances, the question which 
arises is that of the induction of premature labor, by which alone, it may 
be, the safety of the mother can be insured. It is generally, however, 
in the course of labor at the full time that the nature of the case is dis- 
closed, and prompt and decisive treatment called for. 

Having endeavored to ascertain, approximately at least, the amount of 
distortion, we must, in the first instance, decide whether, and if so, to 
what extent, we should give nature a chance. In the minor degrees of 
pelvic deformity, it is always proper to do so, if the strength of the 
patient be not exhausted, and the uterine efibrt not unduly violent. 
When the cranium is of moderate size, it frequently occurs that, even 
in unpromising circumstances, the head becomes so moulded as to pass 
with perfect safety both to mother and child, although probably after a 
tedious labor. If the head is not actually impacted, we may have the 



444 DEFORMITIES OF THE PELVIS. 

choice of three operations — the forceps, turning, or craniotomy; but 
when impaction has taken place, it is impossible to pass the hand, and, 
therefore, turning is struck out of our calculations altogether. In every 
case in which the head is in the cavity or at the outlet, the forceps 
should be preferred, unless, indeed, there is clear evidence that the head 
cannot pass without a reduction of its bulk, when any attempt of this 
kind would be worse than useless. If, however, the head should be at 
the brim, the use of the long forceps involves other and more serious con- 
siderations, and is, indeed, regarded as an operation so dangerous that 
not a few of the most distinguished of modern obstetricians have ex- 
pressed a decided preference for turning over the forceps, and even, 
under certain circumstances, for turning as compared with craniotomy 
when the head is in this particular situation. The general rules which 
are laid down for our guidance in the application of the forceps in 
ordinary cases are, to a limited extent only, of avail here. The altered 
conditions of a deformed pelvis, differing more or less in every case, put 
such rules as serve for the normal pelvis completely out of the question. 
Instead, for example, of applying the blades to the sides of the head, it 
is often necessary to apply them to the forehead and occiput, and, in 
general terms, it may be said that our duty is to apply them in the direc- 
tion where we have most room, and where we can get the firmest grip of 
the cranium. Thus, if the head is arrested at the upper portion of the 
cavity, in consequence of projection of the sacral promontory, the sides 
of the head will probably be strongly compressed in the reduced conju- 
gate diameter. The insertion of the blades of the forceps in such a 
direction would, therefore, be practically a matter of great difficulty, if 
not impossibility ; so that the operator should at once, and without hesi- 
tation, apply the blades to the long diameter of the head in the transverse 
of the brim. 

If the head is at the brim, and the distortion not excessive, we should, 
in the first instance, make a gentle attempt by the long double-curved 
forceps, which should be of considerable strength in construction, in order 
to gain an efficient hold, and to prevent slipping. The operator, bearing 
in mind the immense poAver of such an instrument, will be excessively 
cautious in the amount of force which he employs, and will only persist 
if he observes some indication of yielding. 

Putting, for the moment, out of the question what have been called 
long- forceps cases, there are few points, of undoubted practical import- 
ance, in reference to which greater difference of opinion obtains, than 
with regard to the proportion of cases in which we are justified in apply- 
ing the forceps in the minor degrees of pelvic disproportion. When we 
find one practitioner of experience using it only once in a hundred labors, 
and another, of equal experience, in every eighth or ninth case, it is by 
no means easy to decide who is in the right. For our part, we entertain 
a very confident belief that the practitioner who uses the forceps in less 
than five per cent, of all his cases exposes many of his patients to need- 
less pain and increased risk, and is pretty sure, in his practice, to lose 
more children in labor than he ought. 

When the decision lies between turning and craniotomy, we must first 
be sure that, if we succeed in turning, the head can be got through the 



TREATMENT. 



445 



contraction ; for it sometimes happens that, after turning, delivery can only 
be accomplished by perforating behind the ear. It must, therefore, be 
obvious, that it would be better to perforate, and deliver at once, than to 
turn and then perforate, thereby subjecting the woman to a twofold dan- 
ger. We must also be able to displace the presenting part without em- 
ploying much force, so as to introduce the hand into the uterus ; and it 
is certain that when this cannot be done without violence, it is better at 
once to desist. One of the most important bearings of this interesting- 
subject is whether the child is alive or not, which may be ascertained by 
the stethoscope in the usual Avay. If it is so, the possibility of saving 
the child, — which has sometimes been done when the general condition 
seemed little to encourage the hope of such a favorable result, — is the 
strongest possible inducement we can have for choosing turning, giving 
the child the chance at least, small though it may.be, of which crani- 
otomy necessarily deprives it. 

Among the minor arguments which have been used in support of this 
procedure, may be mentioned the repugnance with which one naturally 
regards any operation which involves the mutilation of the child, and 
the use of instruments instead of the hand. And, again, as has very 
clearly been pointed out by Simpson, there is an undoubted advantage 
in the manner in which " the transit of the cone-shaped head of the child, 
through a somewhat narrow brim, is facilitated by the narrow end of the 
cone (or bi-mastoid diameter of the head) being made to enter and engage 
first in the contracted brim ; and the hold which we obtain of the ex- 
tracted body of the child enables us to employ so much extractive force 
upon the engaged foetal head, as to make the elastic sides of the upper 
and broader portion of the cone (or bi-parietal diameter of the cranium) 
to become compressed, and if necessary indented, between the sides of 
the contracted brim." This will be more clearly understood by a refer- 





Showing Effect of Pressure in Cranial Presentation. Showing Effect of Pressure after Turniuir. 



ence to the diagrams by means of which he illustrates his theory. In 
both figures the dotted line indicates the normal condition of the foetal 
head, which has not as yet been exposed to special pressure. In Fig. 
151, the vault of the cranium (c c) is supposed to present, and if the de- 
formity is such as to prevent the head entering the brim, the eifect of 
pressure is to increase its transverse measurement, while it assumes the 
form indicated by the outlines b 2 1. But if the child be turned, and the 



446 DEFORMITIES OF THE PELVIS. 

base of the skull brought down in advance (Fig. 152), the pressure ex- 
ercised by the walls of the pelvis causes the head to assume the shape 
indicated by the outline h 1 2, with a very manifest mechanical advan- 
tage. But, in addition to this, the operation of turning, when it can be 
effected, even after some time and with some difficulty, is, there is good 
reason to believe, more safe to the life of the mother than that of crani- 
otomy ; so that, even Avhen the child is dead, it is often to be preferred. 
But, when the child is dead, and turning is unusually difficult or imprac- 
ticable, we must consent to waive the objections which have just been 
stated, and substitute craniotomy without delay. This, then, is a ques- 
tion of great practical importance, and is still receiving, at the hands of 
the ablest obstetricians, the attention which it merits ; but the limits of 
this work preclude a more extended analysis of the facts which bear upon 
the subject. 

When the pelvic distortion is excessive, and more than one of the 
diameters is encroached upon to a great extent, as has frequently been 
observed in malacosteon pelves, it may be quite impossible to deliver the 
woman by means of any of the operations which we have mentioned. 
We may, in such instances, have no resource but the Caesarean section, 
or the new operation of G-aatro-elytrotomy ^ by which the danger of open- 
ing the peritoneum is avoided. What specific conditions may be held to 
justify the performance of one or other of these operations, we shall 
afterwards attempt to show ; but, in regard to them, as well as the other 
methods of operative procedure, it is well-nigh impossible to lay down 
hard-and-fast rules, which may seem, in any strict sense, reliable for our 
guidance. An attempt will, however, be made to state the measurements, 
and other conditions, which are held, by the most competent authorities, 
to be Avarrant for the preference of one operation over another. 

The above remarks have had reference to cranial presentations only ; 
but it is, of course, to be kept in view that any other presentation may 
occur along with pelvic deformity, and thus develop new and special 
considerations. An intelligent combination of the general principles 
upon which such presentations are to be managed, and an adaptation of 
these to the special circumstances of the case, will enable the well- 
informed practitioner to conduct such cases also in a skilful and credit- 
able manner. 



HISTORY OF THE FORCEPS. 4^7 



CHAPTEE XXYIII. 

THE FOECEPS. 

History of the Forceps. — Chamherlen^ s Forceps. — Invention of the Pelvic Curve. — 
The Short Forceps : Cases to which it is Applicable. — Reasons for preferring 
the Straight Forceps in most Cases. — Circumstances in which the Forceps is 
Required. — Application of the Forceps : Conditions essential to Safety : Degree 
of Dilatation of the Os : Is it necessary to feel an Ear? Membranes to be Rup- 
tured: Blades to be applied to the Sides of the Head: Forceps to be applied in 
the Opposite Oblique Diameter to that occupied by the Head of the Child. — The 
Operation: Introduction of the ^'Lower'" and "-Ujjper'' Blades in the First 
Cranial Position : in the other Cranial Positions. 

The subject of operative Midwifery naturally commences by a con- 
sideration of the great Prime Clover of Obstetrics, as the Forceps has 
not inaptly been termed. It is scarcely possible to exaggerate the im- 
portance of this instrument, which is simple in construction, easy of 
application, and marvellous in power ; and, besides, the greater frequency 
with which we avail ourselves of its aid, as compared with other methods 
of instrumental and operative assistance, fully entitles it, and its appli- 
cation in practice, to the prominent position in which the subject is in- 
variably placed. 

Xo doubt can be entertained that the ancients discovered, and were 
in the habit of using, an instrument which, in the principle of its con- 
struction, is identical with the modern forceps. The period at which 
the discovery was actually made will probably never be known. It 
does not appear that the knowledge of the subject was general, even 
among the most civilized communities, but it is certain that it was well 
known to the early Arabian physicians. We thus find it mentioned by 
Avicenna, and more particularly described by Albucasis, who lived 
about the eleventh or twelfth century. The latter describes two kinds 
of forceps, the misdaeh and the almisdacJij both being, according to the 
Latin version, circular and full of teeth. It is worthy of note that, in 
the Arab original, which Smellie seems to have seen in the Bodleian 
library at Oxford, the misdaeh is described as straight, and the cdmisdach 
as curved. This important discovery was, however, completely lost sight 
of in the gloom of the dark ages, nor was it till near the middle of the 
seventeenth century that it was rediscovered, and, after a long interval 
of secrecy, introduced into practice. 

This discovery, which was made prior to 1647, has been generally 
attributed to Dr. Paul Chamberlen, but the careful researches of Dr. 
Aveling,^ have clearly shown that we owe it to Dr. Peter Chamberlen, 

1 Obstetrical Journal of G-reat Britain and Ireland — January, 1875, 



448 



THE FORCEPS, 



who communicated it to his sons Hugh, Paul, and another, all members 
of the profession. The secret seems, however, to have been greedily 
guarded by the Chamberlen family for their own profit; and Dr. Hugh 
Chamberlen, who translated into English Mauriceau's work on Midwifery, 
alludes to it in the preface to that work as late as ITltl. Referring to 
the use of the crotchet, he says, " but I can neither approve of that 
practice, nor of those delays, beyond twenty-four hours, because my 
father, brothers, and myself (though none else in Europe, as I know) 
have, by God's blessing and our industry, attained to, and long practised 
a way to deliver women in this case without any prejudice to them or 
their infants ; though all others (being obliged, for want of such an ex- 
pedient, to 'use the common way) do and must endanger, if not destroy, 
one or both, with hooks." As a sort of apology for keeping it secret, 
he adds, " there being my father and two brothers living that practise 
this art, I cannot esteem it my own to dispose of nor publish it without 
injury to them." 

The political troubles of his time obliged Dr. Hugh Chamberlen, on 
two occasions at least, to fly the country and take refuge on the Conti- 
nent, where he made various attempts to dispose of his invention. His 
offer to sell it to the French Government was refused, chiefly on account 
of the failure which had attended his efforts to deliver a woman upon 
whom Mauriceau had resolved to perform the Csesarean operation, and 
which was therefore a case, as we may assume, quite unsuitable for the 
operation by the forceps. He was more successful, however, in Holland, 
where he managed to dispose of his secret to several practitioners, of 
whom Ruysch, the eminent anatomist, was one. From the Netherlands 
to Germany, where it was used by Solingen, and ultimately to France, 
the secret slowly spread, until it was a secret no 
longer, and was recognized in all its importance 
by the most accomplished accoucheurs of the 
day. Long before the operation had thus made 
its way into notice on the Continent, the secret 
in this country had undoubtedly oozed out in 
some quarter ; and, ultimately, the midwifery 
forceps was described and figured by Chapman, 
in his well-known work, as the instrument used 
by the Chamberlens. A very interesting dis- 
covery was made in the old manor-house of a 
small estate near Maiden, in Essex, which had 
been purchased by Dr. Peter Chamberlen to- 
wards the end of the seventeenth century, and 
which had remained in the family till about 
1715. In an old chest in one of the rooms of 
this house, there was discovered, in 1818, a col- 
lection of obstetric instruments, along with old 
coins, trinkets, and the like. Mr. Cansardine, into whose possession these 
relics had fallen, gave an interesting description of them in the 3fedico- 
Chirurgical Transactions, Vol. IX. There were several pairs of forceps, 
showing apparently the various stages of advancement through which the 
invention passed in Chamberlen's hands before he reached what he be- 




Sketch of Chamberlen's For 
ceps. (Eigby.) 



THE SHORT FORCEPS. 449 

lieved to be perfection. Fig. 153 shows one of the most perfect of these, 
in which the blades are fenestrated, and are so constructed as, when 
separately applied, to be articulated together at the shank by means of 
a pivot. This instrument, as perfected by Giflard and Chapman, is essen- 
tially the same as the forceps most frequently used at the present day, 
except in so far as the lock is concerned. 

Up to this time the handles of all the instruments were, as in the 
French forceps to the present day, of iron, and the lock was either a 
pivot, with or without a screw ; a sort of mortise lock, like the blades of 
a pair of scissors ; or the blades were clumsily tied together, after their 
adjustment, by means of a tape or cord. We are certainly indebted to 
Smellie for the simple contrivance which is known as the English lock, 
and also for the adaptation of wooden handles, which give a much better 
hold and purchase. The principle upon which all forceps were essen- 
tially constructed was to adjust the curve of the blades Avith reference 
only to the spheroidal shape of the child's head, so as to make sure of 
securing an efficient hold without risk to the child. The difficulty in the 
application of such an instrument as this, when the head was at the brim 
or at the upper part of the cavity, led to another important modification 
of the forceps, the credit of which is divided between Levret and Smellie. 
It is most likely, however, that the French obstetrician was the real 
inventor ; but it is to be regretted, for the sake of his reputation, that he 
made a secret of it, as the Chamberlens, to their lasting discredit, had 
done before. 

The novelty in question consisted in the adaptation of a second curve 
in the blades, with reference, in this instance, to the curved axis of the 
pelvic canal. This is called the " pelvic curve," and is the invariable 
form of the French forceps of the present day; while, in this country 
also, the straight forceps has been entirely abandoned by some of the most 
eminent of our obstetrical authorities. This vaHety was originally con- 
structed in order to overcome difficulties at the brim and high in the cavity ; 
and it is, therefore, to these that it is chiefly applicable ; although as has 
been said, many prefer this form in all cases, and allege that it is easier 
in application, and safer both to mother and child. We do not intend to 
enter at any length upon the controversy of single versus double- curved 
forceps ; but it is proper to mention that Dr. Barnes, the latest English 
authority on the subject of operative midwifery, pronounces, in very em- 
phatic terms, in favor of the latter, in all cases, whether at the brim, in 
the cavity, or at the outlet. For our part, although we cannot subscribe 
to this doctrine, we are quite confident as to the superiority of the pelvic 
curve in all cases where the head is at the brim or high in the cavity. 

Long and Short Forceps are described by all English writers as dis- 
tinct varieties of the instrument, and are sold by the makers under these 
names. The Short Forceps, as usually constructed, is an instrument 
about eleven inches in length, the measurement from the lock to the tip 
of the blades being a little over seven inches. Each blade is fenestrated, 
the aperture being destined, on each side, to receive the parietal protu- 
berances. The blades are curved, so as to measure between their widest 
part about three inches, and from tip to tip, when closed, not more than 
an inch. This instrument, when made without a pelvic curve, is known 
29 



450 THE FORCEPS. 

as Smellie's forceps, and is still used to a considerable extent in this coun- 
try. When it is applied to the child's head within the pelvis, the handles 
should be about an inch apart. It is scarcely necessary to observe, what 
is equally applicable to any variety of forceps, that the blades should be 
made of steel of the finest temper ; otherwise, they are constantly apt 
to slip over the head by yielding of the metal. The edges are highly 
polished, and bevelled off in every direction with great care, so as to 
avoid the possibility of injuring the scalp of the child or the soft parts of 
the mother. Covering the blades with leather was once practised, but 
this has now properly fallen into disuse, as rendering the instrument more 
difficult of introduction, and more likely to convey infection. Nor is the 
practice of covering them with a composition of gutta-percha to be com- 
mended ; and when properly made, the clean, smooth metal is, on all ac- 
counts, to be preferred. The short forceps is suitable for the extraction 
of the head from the outlet and lower part of the pelvis ; but if the head 
is higher in the cavity, this instrument, although it may still be used with 
difficulty, is not to be recommended when one more efficient is at hand. 
Its use should be limited to those instances in which it is possible, after 
adjusting the blades, to close them when the lock is still quite clear of the 
external parts. If the lock passes within the vulva, there is considerable 
danger — especially when the woman is under the influence of anaesthetics, 
and is thus unable to give any evidence of particular suffering — of pinch- 
ing in some portion of the soft parts, and inflicting serious laceration. 

To obviate this risk, and at the same time to render the forceps capa- 
ble of more extended application, we have always advocated the employ- 
ment, in ordinary practice, of an instrument which is both longer and 
stronger than the ordinary short forceps. Such an instrument as this, 
which fulfils equally well all the purposes of the short forceps, is also 
applicable to cases in which the head occupies the middle third of the 
cavity, or is even a little higher. In these latter cases, the lock is still 
external, and the power of the instrument is considerably increased. The 
handles are stronger, and the blades thicker, than in the ordinary short 
instrument ; for it is a fundamental rule, in the construction of the mid- 
wifery forceps, that, for obvious mechanical reasons, we must increase 
the strength in proportion to the length of the blades. And, in doing so, 
it is also proper so to construct the handles as to give the operator suffi- 
cient power ; as no greater error can be committed than to sacrifice power 
to elegance, or to a dislike to give the instrument a formidable appear- 
ance. The following remarks by Dr. Barnes are so apposite to this, that 
we quote them here. " It has been sought," he says, " to make an in- 
strument safe by making it weak. There can be no greater fallacy. In 
the first place, a weak instrument is, by the mere fact of its weakness, 
restricted to a very limited class of cases. In the second place, if the 
instrument is weak it calls for muscular force on the part of the operator. 
Now, it is sometimes necessary to keep up a considerable degree of force 
for some time, and not seldom in a constrained position. Fatigue follows ; 
the operator's muscles become unsteady ; the hand loses its delicacy of 
diagnostic touch, and that exactly-balanced control over its movements 
which it is all-important to preserve. Under these circumstances, he is 
apt to come to a premature conclusion, that he has used all the force that 



FORCEPS FOR ORDINARY USE. 



451 



Fiff. 154. 



is justifiable ; that the case is not fitted for the forceps, and takes up the 
horrid perforator ; or he runs the risk of doing that mischief to avoid 
which his forceps was made weak. The faculty of accurate gradation of 
power depends upon having a reserve of power. Violence is the result of 
struggling feebleness, not of conscious power. Moderation must ema- 
nate from the will of the operator ; it must not be looked for in the im- 
perfection of his instruments. The true use of a two-handed forceps is 
to enable one hand to assist, to relieve, to steady the other. By alter- 
nate action the hands get rest, the muscles preserve their tone, and the 
accurate sense of resistance which tells him the minimum degree of force 
that is necessary, and warns him when to desist." 

It is, perhaps, natural that an operator should prefer that form of 
forceps to the use of which he has been trained, and upon which he 
knows, by experience, that he can thoroughly depend in times of danger 
or difficulty. In confessing, however, a personal predilection for the 
straight forceps, it is proper to observe that many of the most experi- 
enced and distinguished practitioners, both in this country and abroad, 
express a decided preference for the pelvic 
curve. Personal experience, which is cor- 
roborated by that of many able and experi- 
enced accoucheurs, prevents us from per- 
ceiving the strength of their arguments, or 
the justice of their conclusions ; and we 
object more particularly to the assertion that 
the straight forceps is specially dangerous 
to the child. It may well be that the pelvic 
curve in the hands of those skilled in its use 
is equally efficient. That it is so, cannot, 
indeed, be doubted, and it is possible that, 
when once adjusted, the danger of slipping 
is less when used by the inexperienced, but 
we conceive that such problematical advan- 
tages are more than counterbalanced by the 
following: First, the blades are more easily 
introduced, with reference to the position of 
the child's head, if the operator has but one 
curve to think of; second, the two blades 
being the same, no mistake can possibly be 
made between the upper and lower, or an- 
terior and posterior blade ; and third, that 
if it should be found necessary to alter the 
position of the head by rotation, this can 
only be effected by the straight instrument. 

The forceps, the use of which we recom- 
mend to young practitioners, who generally 
possess but one instrument, is of a size in- 
termediate between the short forceps and what will presently be described 
as the long forceps. (See Fig. 154.) It is, as already mentioned, 
applicable for all the purposes of the short forceps, but by means of it 
we are able to operate quite as easily when the great diameters of the 



straight Forceps for Ordinary Use. 



452 



THE FORCEPS. 



Fiff. 155. 



head are on a level with the middle plane of the pelvis. It is fourteen 
inches in length, the blades to the lock being nine, and the handles five 
inches. The fenestrse are four and a half inches in length, and some- 
thing less than an inch and a quarter in the widest part. The distance 
between the blades in the widest part of the curve 
is three inches, and at the tips a little under an 
inch. The handles are lengthened to secure a 
better hold.^ 

[In this country the straight forceps are scarcely 
ever used. The late Professor Charles D. Meigs 
recommended the short double curved instrument 
of Professor Davis, of London, and for a long 
time it was a favorite with the graduates of the 
school in which the former taught. The inventor 
of these forceps, however, expressly stated that 
they were only applicable to cases in which the 
head was arrested at the outlet or in the cavity 
of the pelvis, and that they could not be applied 
at the brim. Davis's instrument, or some modi- 
fication of it, continues to be relied on in most 
cases by many experienced and successful prac- 
titioners. 

One of the most important improvements of 
this valuable instrument which has been made by 
any American accoucheur, is that of the late 
Professor Hodge, of the University of Pennsyl- 
vania, who endeavored to combine all the ad- 
vantages of the various suggestions of others, 
while he rejected everything which he deemed 
objectionable. This forceps, its inventor claimed, 
has the followino; advantao;es over those of 
others : — 

1. Its weight is diminished (to seventeen 
ounces avoirdupois) without any diminution of its strength. 

2. The pelvic curve is such that the perineum cannot be dangerously 
pressed upon when the instrument is applied at the superior strait, while 
any loss of power which may result from this increased curvature, is 
compensated for by a bend of the handles in the opposite direction, 
which preserves the direct line of traction. 

3. The shanks are closely approximated, and occupy nearly parallel 




Davis's Forceps. 



1 It would appear that, in some quarters, the words "short" and "straight," as 
applied to the forceps, are admitted as synonymous terms. This, or (what is only 
too probable) some confusion in the text, seems to have led to the idea that the 
author of this work upholds the use of the short forceps. This he would beg to 
re^Dudiate, and he refers to Fig. 154 and to its dimensions as now stated, in refutation 
of what has been imputed to him by critics, who in other respects were generous and 
indulgent to a fault. The instrument here described is, in point of fact, identical, 
or nearly so, with what is known in Ireland as Beatty's forceps, and is almost iden- 
tical in measurement, although stronger in construction, with a straight forceps 
described by Dr. Graily Hewitt some years ago. The young obstetric practitioner 
should have nothing to do with the short forceps, unless he should be so circum- 
stanced as to have nothing better at hand. 



hodge's forceps. 



453 



lines, one anterior to the other, until nearly at the point where they join 
the blades, when they separate abruptly. Thus undue stretching of the 
vulva and the danger of lacerating the perineum are prevented. 

4. The blades are of nearly the same width in all their parts, so that 
the fenestrae have the outline of an elongated oval rather than the " kite" 
shape of those of the French and English instruments. This not only 
secures a firmer hold on the child's head, but allows the parietal pro- 
tuberances to jut through the opening, so that the blades occupy no 
space in the cavity of the pelvis. 

Fi£?. 156. 




Hodge's Forceps. 



5. The surface of the blades which comes in contact Avith the child's 
head is curved not only from the handle towards the extremity, but like- 
wise from side to side, as was suggested by Haighton. In this manner 
the tissues of the child are always safe, as there is always a flat surface 
in contact with them. 

6. The cephalic curve is slight at the extremity of the blades, and 
gradually increases as the shanks are approached for two-thirds of their 
length, at which place the space between the blades is two inches and a 
half. From this point the width diminishes quite rapidly until the 
shanks are reached. In this manner the force employed is equally dis- 
tributed over the child's head, while the instrument is rendered less 
liable to slip, because as the head is compressed it will tend to glide 
deeper and deeper into the grasp of the blades. 

7. The blades are united by Siebold's lock, which has all the steadi- 



454 



THE FORCEPS. 



ness of the French, and is as easily adjusted as the lock of the English 
instrument. 

When made as directed by Professor Hodge, the whole length of the 
instrument is sixteen inches. From the lock to the extremity of the 
blades is nine and a half inches. The length of the blades proper, in a 
direct line, is six inches. The extremities of the blades are half an inch 

apart when the handles are in con- 
Fig. 157. tact, while the greatest width be- 
tween the blades is two and one- 
half inches. 

This instrument has been exten- 
sively employed in this country, 
through the influence of its eminent 
inventor. Still, the teaching of the 
Jefferson Medical College has al- 
ways been in favor of some form of 
Davis's forceps. Professor Meigs, 
who so long occupied the chair of 
obstetrics in that school, and who 
for so many years was the contem- 
porary teacher of Hodge, in Phila- 
delphia, as has already been stated, 
recommended Davis's short double- 




curved instruments to the large 
classes of students w^hich annually 
gathered to be instructed by him. 
His successor, Professor EUerslie 
Wallace, has modified this instru- 
ment, making one with substantially 
Davis's blades and Hodge's handles. 
The whole length of the forceps in 
a direct line, from the extremity of 
the blade to the end of the blunt 
hook on the handle, is fifteen inches. 
From the extremity of the blade to 
the lock is eight and one-half inches. 
The extremities of the blades are 
half an inch apart. The greatest 
wauace's Forceps. ^idth of the spaco between these is 

about one-third of the distance from 
the shanks, and is two inches and a half. The fenestrae have the oval 
outline of the original Davis and the Hodge forceps, but the shanks are 
more closely approximated than in the former instrument. They are 
nearly parallel, and that of the female occupies a position in front of that 
of the male blade. This is an important change, and insures the integrity 
of the perineum, so that the instrument can be applied high up in the 
cavity of the pelvis or at the superior strait, without endangering any of 
the mother's tissues. 

The editor has used Professor Wallace's forceps for the past decade, 
in both private and hospital practice, almost to the exclusion of the 



smith's forceps, 



455 



Fig. 158. 



eclectic instrument of the late Professor Hodge. When the head is 
high up in the }3elvic cavity, or at the superior strait, they are more 
easy of application, and hold more firmly than the instrument of 
Hodge. 

Dr. Albert H. Smith, the lecturer on Obstetrics at the Nurse's Home 
in Philadelphia, in a discussion on the use of the obstetric forceps at the 
Obstetrical Society in that city, in 1872, announced his preference for 
the Davis forceps, because their grasp 
is more firm, and they slipped less 
easily than Hodge's. In the American 
Journal of the Medical Sciences for 
July, 1869, he published a description 
of a modification of this instrument, 
which adapts it to cases in which the 
head is high up in the cavity, or at the 
superior strait. The peculiarity of the 
instrument is that it is made portab.e 
by a joint in the handles, by which the 
forceps can be separated into two parts, 
and " one of the handles can then be 
joined to a vectis, and the instrument 
used either as a vectis or a blunt hook. 
A separate pair of short handles is pro- 
vided for cases where the short forceps 
would be preferable, as where no com- 
pression is desirable. The connection 
is made by means of a pivot and socket 
joint about an inch below the lock, ad- 
justing very firmly and readily by a 
spring-catch, raised in separating them 
by means of a concealed lever upon the 
inside, of the handle. The instrument 
is thus rendered more portable without in the slightest degree impairing 
its strength. The blades are of the Davis pattern, and the lock a simple 
button, proved by experience to be the safest and most readily adjustable 
of any in use. The long handles for compression permit an approach of 
the blades at their widest part of two and a quarter inches ; the short 
handles for traction in ordinary cases only two and three-quarter inches. 
The jointed handle could be adapted to any pattern of blade desired. 
The whole set, taken to pieces, can be put in a leather bag nine inches 
in length and two and a half in width." 

The late Prof. George T. Elliot, of New York, used and recommended 
a forceps which is essentially a modification of the instrument used by 
the late Sir James Y. Simpson. The total length of the specimen of Dr. 
Elliot's forceps, which we measured, is fifteen inches in a direct line from 
the extremity of the handles to that of the blades. From the lock to the 
end of the blades is nine inches. The greatest distance between the 
blades is three and a quarter inches, while the extremities of these are 
an inch apart. The blades are united by the English lock, and the handles 
are composed of steel and wood. In one handle is a bolt which, when 




Smith's Forceps. 



456 



THE FOECEPS. 



screwed out by a burr in the handle, for that purpose, limits the com- 
pression exerted by the instrument to any extent desired by the operator. 
In 1872, Prof. F. M. Robertson, of Charleston, South Carolina, pub- 
lished a description of the forceps which he uses, and which is in reality 
a modification of Hodge's. The blades are those devised by Hodge, ex- 
cept that the pelvic curve is slightly increased. The blunt hook on the 
handles of Hodge's forceps has been abandoned, and the latter, which are 



Fiff. 159. 



Fiff. 160. 




EUiot's Forceps. 




Eobertson's Forceps. 



composed partly of steel and partly of wood, have been reduced 2.8 
inches in their length. The length of the shanks is also reduced .5 of an 
inch, making the entire length of the instrument from the extremity of 
the handles to that of the blades in a direct line 13.5 inches. 

Dr. Robertson prefers that women should occupy the dorsal position 
during childbirth, and the chief advantage which he claims for his modi- 
fication of the forceps is that it can be applied without changing the posi- 
tion of the patient. 

The instruments of Hodge and Wallace were generally used in Phila- 
delphia until about five years since, when Dr. William F. Jenks returned 



457 

to this country after several years' sojourn in Europe. He brought with 
him a pair of Simpson's forceps, accurately made according to the model 
of the famous Edinburgh Professor. Dr. Jenks's persistent advocacy of 
this instrument induced many of his friends to try it. The result is that 
it is rapidly groAving into favor among Philadelphia obstetricians. The 
total length of Simpson's instrument, from the extremity of the blade to 
that of the handle, is thirteen and three-quarter inches. The distance 
from the lock to the extremity of the blade is eight and one-half inches 
in a direct line. The blades and shanks are therefore of precisely the 
same length as those of Wallace's forceps, but they are one inch shorter 
than the eclectic instrument of Dr. Hodge. The extremities of the blades 
are one inch apart, the handles being in contact, or one-half of an inch 
more than either Hodge's or Wallace's forceps. The greatest space 

Fi-. 161. 



Simpson's Forceps. 

between the blades is three inches, or one-half of an inch more than that 
of the instruments of Hodge and Wallace, and three-fourths of an inch 
more than the long forceps of Smith. The shanks are about two inches 
long, and run parallel to one another three-quarters of an inch apart. 
The blades are united by the English lock, which is made very loose, so 
that the handles have considerable play. This facilitates locking. The 
handles are composed of wood and steel, and at their upper extremity 
terminate in hollowed transverse projections or shoulders, which enable 
the instrument to be firmly grasped. 

This is a fair description of the various models of forceps now in com- 
mon use in America. Various other modifications are employed by in- 
dividual practitioners. Whichever one of these varieties may be selected, 
it will fill the requirements under all ordinary circumstances ; whereas, 
if the recommendations of the author are followed, the physician will be 
forced to have two pairs of forceps at hand, if he expects to apply them 
at the superior strait. When supplied with Hodge's, Wallace's, Smith's, 
or Simpson's instruments, the operator will find the short forceps entirely 
unnecessary. Any one of these can be applied anywhere in the partu- 
rient canal. 

Several thincrs have to be taken into consideration in the selection of a 

o 

pair of forceps. From the descriptions of the various instruments in use 
it will be seen that they may be divided into two distinct classes ; those 
which are forcible compressors, and those which have but little power to 
diminish the size of the child's head. In this first class may be included 
the instruments of Hodge, Robertson, Wallace, and Smith. Of these, 
the last is the most powerful compressor, as the space between the blades 
is only two and a quarter inches at its widest part, Avhile the instruments 
of Hodge, Robertson, and Wallace measure two and a half inches in the 
Avidest part. On the other hand, the forceps of Simpson and Elliot pos- 



458 THE FORCEPS. 

sess but little compressing power, the blades of one having three and the 
other three and a quarter inches between them at their widest point. Of 
those varieties which may be stjled powerful compressors the editor has 
always preferred the forceps of Professor Wallace. The advantages of 
these are the ease with which they are introduced, owing to the great 
pelvic curve, and the tightness of the grasp. Of the. second class, Simp- 
son's instrument, when properly constructed, appears to us to be the best, 
and is the one which we now use. — P.] 

Cases requiring the use of the forceps are very variable in their 
general features, but most of them may be referred to one or other of 
the following groups. We may have, in the first instance, cases in which 
everything is normal save expulsive power, which may utterly fail as the 
period of delivery approaches : this failure of the vis a tergo is familiarly 
known as " uterine inertia," and from it arises, more frequently than 
from any other cause, the necessity for operative assistance. In another 
group, the operation is rendered necessary by a minor degree of pelvic 
deformity, at the outlet or in the cavity — of which flattening of the sacrum 
is an example, probably of more frequent occurrence than is usually sup- 
posed. The application of the forceps, when the head is at or above the 
brim, is less frequently required, and is attended with special difficulties 
and dangers which will be duly considered. Any mechanical obstruction, 
however, whether of the hard or soft parts, including the abnormal 
rigidity of any portion of the parturient canal, may be an unmistakable 
warrant for operative assistance. In occipito-posterior positions, and in 
face presentation, the forceps may be found necessary either for rectifi- 
cation or direct extraction ; and in convulsions, or any condition calling 
for speedy delivery, it may also be necessary to use the forceps if the 
labor has sufficiently advanced to admit of the safe application of the in- 
strument. Some of the rarer circumstances calling for the forceps have 
already been mentioned, such as certain exceptional cases of rupture of 
the uterus, placenta preevia, or funis presentation. In cases of breech 
presentation, or after turning, it is frequently necessary to apply the 
forceps, when the trunk has been born, in order to extract the head from 
the soft parts and protect the child from sufibcation. The instrument, 
being specially constructed for application over the spheroidal cranium, 
is only applicable, as is evident, to a limited class of cases. For other 
presentations, which may require operative assistance, special me- 
chanical aids must be sought. The necessity for operation by the forceps 
arises more frequently in primiparse than in women who have already 
borne children. 

Application of tlie Forceps. — Before, in any case, making the slightest 
attempt in this direction, we must be sure that neither the bladder nor 
rectum is distended, and this caution is especially required as regards 
the bladder, from which the contents must, if necessary, be withdrawn 
by the catheter. An essential condition is, according to all authorities, 
complete dilatation of the os, but some difficulty unfortunately seems to 
exist in determining what we are to understand by " complete dilatation." 
The cases which are undoubtedly most favorable for operation are those 
in which the os is absolutely obliterated or drawn up beyond the reach 
of the operator over the advancing head. But if we limit the employ- 



APPLICATION OF THE FORCEPS. 459 

ment of the instrument to these cases alone, we shall certainly withhold 
assistance in many in which we might deliver the woman with perfect 
safety. Obliteration of the os, or actual continuity of the uterine with 
the vaginal canal, is no doubt desirable, but we must not admit as true 
the statements of those who tell us that it is essential to safety. To 
wait until the lip of the os can no longer be felt, as some have said, is to 
•wait for what may possibly never occur ; and, in like manner, if we ac- 
cept the rule as correct, that we are never to pass the blades of the 
forceps within the uterus, we may allow the period to pass at which we 
may, by prompt action, save the life of the child. 

Complete dilatation of the os is, indeed, in a sense, absolutely essen- 
tial, and it is certain that a greater degree of dilatation is necessary for 
this than for any other of the operations for delivery. But complete 
dilatation, in the sense which we would attach to the term, does not 
imply that tlie anterior lip of the os has passed out of reach beyond the 
head, but merely such dilatation as will admit of the safe passage of the 
head. In many cases, then, we are justified in passing the blades partly 
within the uterus ; and, although it is quite proper to wait as a rule for 
what we call complete dilatation, all that is absolutely essential is such 
dilatation as may admit of the passage and adjustment of the blades with- 
out danger of laceration. There can be no doubt that, in a considerable 
number of cases, recession or retraction of the os, and especially of its 
anterior lip, does not occur immediately upon full dilatation, nor, it may 
be, for a considerable period thereafter. 

The possibility of feeling an ear has been very generally looked upon 
as important and, by some, as an essential condition, in the absence of 
which we would never be justified in operating. That the ear may often 
be reached with ease, when the other operative conditions are fulfilled, 
is undoubted ; and, in cases in which we are only called in when a large 
caput succedaneum has in some measure obliterated the landmarks on 
the surface of the cranium, it is really important that we should seek for 
and observe the ear, with the view of determining the exact position of 
the head. But to accept this as a rule for our guidance in every case, 
is both unnecessary and improper, as the ear, in some cases in which we 
may hold the operation to be perfectly justifiable, can only be reached 
with difficulty, or wdth an amount of violence which may greatly aggra- 
vate the suff"e rings of the patient. 

The forceps must be applied directly to the surface of the child's 
head, and it is therefore absolutely necessary that the membranes be 
ruptured, should this not have already spontaneously occurred. We 
have been summoned with a view to delivery by the forceps in a case 
in which it was stated that the os w^as fully dilated, although it turned 
out that the os was still very slightly dilated and only reached with diffi- 
culty in the posterior part of the pelvis, the thin uterine w^all being still 
extended over the surface of the scalp. Such a condition could, with 
ordinary care, scarcely lead to an error in practice, but the possibility 
of a mistake should nevertheless be borne in mind by the inexperienced. 

If possible, but with exceptions to be afterwards noticed, the blades 
should be applied to the sides of the child's head. To do this with accu- 
racy, it is necessary that the actual position of the head be made out 



460 THE FORCEPS. 

■with perfect certain t3^ This may he ascertained, as has heen explained 
in a former chapter, by a careful examination of the sutures and fonta- 
nelles, and of the relation which these parts hear to the pelvic canal ; 
and, as there are four possible cranial positions, Ave must first be sure 
with which of them we have to deal, before we take the instrument into 
our hands. It is only, as we have said, when exceptional difficulties 
exist that we require to examine the ear. No one, therefore, is qualified 
to attempt delivery by the forceps unless he is familiar with the laws 
w^hich regulate normal parturition ; and there is, in fact, no operation or 
contingency in midwifery practice, in which a thorough know^ledge of the 
mechanism of labor, in all its details, is so essential as this. It is unne- 
cessary to inform any one familiar with the details of normal parturition, 
that the method of application will depend upon the situation of the 
head. In proportion to the proximity of the head to the external parts, 
the movement of rotation will be found, in the ordinary position, to have 
occurred ; and, therefore, the nearer it is to the outlet, the more do we 
require to apply the blades in the transverse diameter of the pelvis, in 
our endeavor to adjust them to the sides of the head. When, however, 
the head is higher, its position is more decidedly oblique, and, even at 
the outlet, a little of this obliquity still obtains ; so that, to insure their 
application to the sides of the head, w^e must apply them in the opposite 
oblique diameter to that in ivhich the child^s head lies. 

Having satisfied ourselves as to the position of the head, and that the 
conditions exist which w^arrant the performance of the operation, w^e pre- 
pare the forceps by warming and greasing the blades. The patient, who 
lies in the ordinary midwifery position, should be carried quite to the 
edge of the bed, so that her hips may even project a little over it, and 
it is advisable that she should be brought, before commencing the opera- 
tion, into a state of full anaesthesia. We should be perfectly satisfied 
w^ith her posture before commencing the operation, as a change in this 
respect after one blade has been introduced is not free from risk. If the 
head is at the outlet and resting on the perineum, the blades are to be 
introduced, so that the handles shall be diveGted fortvards under the pubic 
arch ; if rotation has not yet occurred, and the head is consequently in 
the lower part of the cavity, they Avill, with reference to the erect pos- 
ture, be directed doivmvards ; and, if the head is higher in the pelvis, 
they will be directed more or less hackiuards towards the perineum. If, 
however, it is still high in the pelvis, or at the brim, we should use the 
double-curved long forceps ; for, our object being to apply extracting 
force m the axis of that part of the pelvis which the head occupies, we 
must discard the straight forceps if we find that the shanks of the blades 
press upon the fourchette. This we do for various reasons, to be after- 
wards more particularly explained in connection with the subject of the 
double-curved forceps, not the least of which is the danger to the integ- 
rity of the perineal tissues which would accrue in an attempt to pull the 
head backwards in a direction even approaching to the axis of the brim. 

Let us suppose the head to be in the position which in seventy per 
cent, of cranial presentations it occupies, — in the right oblique diameter, 
with the forehead towards the right sacro-iliac synchondrosis, and the oc- 
ciput to the left foramen ovale. The blades, in this case, are to be passed 



APPLICATION OF THE BLADES. 



461 



in the direction of the left sacro-iliac synchondrosis and the right fora- 
men ovale, or, in other words, to the poles of the left oblique diameter 
of the pelvis. With reference to the position of the woman as she lies on 
her left side, we speak of the " upper" and " lower" blades. It is of no 
great importance which of these blades is first introduced, but it is pro- 
per that the operator should have a definite plan of procedure, which he 




Introductiou of the Lower Blade. 



may adopt in every case. If he introduce, as we are in the habit 
of doing, the lower blade first, he grasps one of the blades with the 
fingers of his right hand as he would a catheter, and holds it for a moment 
diagonally across the breech of the woman, with the concavity of the blade 
turned towards her, the point downwards and to the left, the handle up- 
wards and to the right. If thus held, it will correspond to the left ob- 
lique diameter, and from this it should not deviate or twist in any way 
durinof its introduction. Two or three fin";ers of the left hand, which 
have been duly anointed, are then to be passed into the vagina, over the 
left ischial tuberosity, in the direction of the corresponding sacro-sciatic 
ligaments, with the palmar surface upwards, until the head is reached. 
The blade is then passed along the fingers, and, if the os is still distin- 
guishable, it is to be carefully guided within it. If the handle is no^ 
gradually depressed, and at the same time gently pushed onwards, it will 
generally glide over the convex surface of the cranium without the slight- 
est difficulty or danger. Should the blade turn or twist in the direction 
either of the hollow of the sacrum or of the foramen ovale, it is on no 
account to be replaced forcibly, but is to be partially withdrawn by raising 
the handle, and re-introduced with greater care. The handle is then 
carried towards the perineum, and intrusted to an assistant while the in- 
troduction of the upper blade is being effected. 



462 



THE FORCEPS, 



The operator should take the second blade with his left hand, so that 
it diagonally crosses the breech as before, but with the point above and 
to the right, and the handle downwards and to the left. The fingers of 
the right hand are then passed in the direction of the right foramen ovale 



Fig. 163. 




Introduction of the Upper Blade. 



until the head is reached, aud along their palmar surface, which is 
turned downwards,' the blade is then to be introduced. The reason for 
bringing the woman quite to the edge of the bed now becomes obvious, 
as it is only in this way that the handle of the upper blade can be suffi- 
ciently depressed to admit of its easy introduction. This blade is intro- 
duced, as will be observed, in front of the lower blade, as it is only in 
this way that the two parts of the forceps will lock.^ The hand is now 
to be steadily raised, when, under the direction of the fingers, the blade 
will glide over the right side of the child's head. An excellent guide 
during this part of the operation is derived from an observation of the 
inner or metallic surface of the handle, which should remain parallel 
with the corresponding surface of the lower blade, and the earliest de- 
viation of the blade from its proper course will be found in an inclination 
of this surface to one side or another. Should this occur repeatedly, 
after partial removal and re-introduction of the blade, it may be advisable 
to withdraw the lower blade, and introduce it with reference to the other, 
as there is the possibility of a mistake having been committed as to the 
position of the head, and it is besides a matter of far greater importance 
to have the blades exactly opposite to each other, than to have them 
accurately adapted to the transverse diameter of the head. The best 



' We have frequently observed that students who may he practising these details 
with the machine and phantom commit the error of passing the second blade without 
any reference to the direction of the lock in the first. This error cannot possibly be 
committed in practice if the direction's here laid down are observed. 



.^ 



THE FORCEPS APPLIED. 



463 



test of a proper application of the forceps is the perfect locking of the 
blades after their introduction. Fig. IQ-L shows the blades as adjusted 
for the first position, the head being in the pelvic cavity, as is indicated 



Fi^. 164. 




The Forceps Applied. 

by the direction of the handles. The blades being separated by the 
transverse diameter of the head, the extremities of the handles are about 
an inch apart. 

When the head occupies the second cranial position, the blades are 
to be applied to the poles of the right oblique diameter. The lower 
blade is therefore introduced in the direction of the left foramen ovale, 
from which point the handle is first directed upwards and to the left, 
and then depressed downwards and to the right. The upper blade is 
then introduced in the direction of the right sacro-iliac synchondrosis, 
taking care that it is passed in front of the lower blade, and that the 
metallic surfaces of the handles retain their parallelism as before. In 
third positions, the forceps must be applied in exactly the same way as 
when the head is in the first ; and in the fourth presentations as for the 
second. 



464 THE FORCEPS, 



CHAPTEE XXIX. 

THE FORCEPS (Continued). 

Action of tlie Forceps : 1, hy Compression ; 2, by Traction] S, ty Douhle-Lever 
Action. — Mode of Extraction : Management and Direction of the Handles at 
various Stages of Delivery. — Delivery hy the Forceps in Occijnto-Posterior 
Positions: Rotation hy the Forceps : Extraction of the Forehead Forwards. — 
The '■'• Long Forceps" : Reasons for Preferring the Pelvic Curve in this Ope- 
ration: Description of the Instrument: Cases in ivhich the Long Forceps is 
a2)plicable : Directions for the Operation: Blades to he applied to the sides of 
the Pelvis: Mode of Introduction of the Lower and Upper Blades: Relation 
of the Blades to the Surface of the Cranium. — Use of the Forceps in Presenta- 
tions of the Face. — Procedure when the Head is retained after Ex^iulsion of 
the Trunk. — Modifications of the Instrument: Ziegler's, Radford's, As salini's 
and other Forceps. 

The forceps acts mechanically in three different ways in effecting the 
object which we have in view: by compression, by traction, and by a 
double-lever action. In so far as compression is concerned, a certain 
degree of this is essential, in order to grasp the head with the blades, 
which otherwise would slip off, or would only be precariously maintained 
in their position, under certain circumstances, by the pressure of the 
walls of the parturient canal. But, by compression, something more is 
implied than mere grasping; for by it, as is obvious from the yielding 
nature of the sutures and fontanelles, the actual diameters of the cranium 
may be materially diminished. It is to be remembered, however, that 
the forceps is usually applied to that portion of the cranium which is 
least subjected to pressure, and that, therefore, as a rule, little is to be 
gained by diminishing these diameters. We may, in fact, assume that 
the pressure which is necessary to insure such a grasp of the head as 
may render it impossible for the blades to slip under moderate efforts, 
will effect all the compression which is desirable. Many recommend that 
a piece of cord or tape should be firmly tied round the handles in order 
to keep up sustained pressure on the cranium, and it is for this that the 
depression near the extremities of the handles, which is characteristic of 
all English forceps, is intended. This mode of procedure is not to be 
commended, as such serious and sustained pressure may endanger the 
life of the child. The power exercised by the hands of the operator, if 
only the handles are of proper size, is quite sufficient for our purpose, 
and being necessarily intermittent, is free from the danger which attaches 
to continuous pressure upon structures so delicate and important as are 
contained within the cranium. Sometimes, when it is necessary to use 
very considerable force, the full extent of possible compression must be 



ACTION OF FORCEPS. 465 

resorted to, but this more with the view of maintaining a secure hold 
than of gaining much bj mere compression. In such a case, the corner 
of a towel which has been dipped in water may be tightly bound round 
the handles at the depression alluded to, when the remainder of the 
towel being wrapped round the handles will give a better hold and more 
power ; but, when this is done, the pressure should always be relieved 
during the intervals between the pains, or when at any other time we 
make a periodical pause in our extractive efforts. The amount of com- 
pression which is safe will depend in no small measure on the construc- 
tion of the forceps ; and, in an instrument, such as are many of those of 
French manufacture, with an interval of half an inch only between the 
tips, the pressure Avill certainly be attended with more risk than when 
these are, as they should be, an inch or nearly so apart. 

The forceps acts also by Traction ; but this force is not applied alone, 
as in drawing a cork from a bottle, but in combination with the third mode 
of action of the instrument, — viz., that of a Double Lever. The forceps, 
as almost invariably constructed with the English or other similar lock, 
is composed of two levers — the fulcrum of each being the lock. This 
enables us, by a swaying movement of the hands, to apply extracting 
force, partly by leverage and partly by traction, to each side of the head 
successively, without the danger which attaches to the single lever or 
vectis, where it is necessary to find a fulcrum in some part of the pelvic 
wall. Care must be taken, however, not to carry this double-lever action 
too far, for there is no doubt that when we sway too much there is both 
loss of power and increase of danger. The more important action un- 
doubtedly is steady traction in the proper axis. 

When the blades have been adjusted to the satisfaction of the operator, 
he now proceeds to the actual operation of extraction. As his object 
should, in most cases, be rather to aid than to supersede the natural efforts, 
he must merely assist the pains should they be present, and pause when 
his assistant informs him that the uterine action has ceased. This leads 
us to observe, that, if it be practicable, the assistance of another practi- 
tioner should always be obtained ; for not only is there thus a division of 
responsibility, but the operator has the great advantage of efficient and 
intelligent aid, to which he can trust for the management of chloroform, 
the steadying of the uterus, and many other points of detail, which it is 
impossible to obtain at the hands of those who are ignorant or inexperi- 
enced. 

When the action of the uterine fibres has ceased — as in cases of com- 
plete inertia — he should imitate nature by applying extracting force at 
intervals corresponding to the ordinary duration of natural pains. The 
handles should be grasped by both hands, two of the fingers of one hand 
being passed up so as to impinge upon the head. The object of this is 
to ascertain the earliest indication of slipping of the blades, w^hich is 
always more apt to occur when the distance between their extremities is 
more than an inch. So soon as he feels that his finorers are leavins; the 
surface of the scalp under the influence of his efforts, he knows that the 
instrument is losing its hold. The blades should then be disarticulated 
and pushed back to their original position ; and, upon renewed efforts, he 
makes use of a little more compression, thus striving always to effect 
30 



466 THE FORCEPS. 

the dislodgment of the head with as little of actual force as may be 
necessary. The force should be applied as nearly as possible in the 
direction of the axis of that part of the pelvic canal within which the 
head lies ; and the operator should pull steadily, with or without a slight 
swaying motion of the handles from side to side. 

If the head is by these efforts dislodged from the situation in which it 
has been arrested, and moves downwards into a lower plane of the pelvis, 
this may, in the presence of efficient pains, be all that is required, as 
nature in some cases will often complete the delivery. It is better, how- 
ever, at this stage, not to withdraw the blades, but merely to disarticulate 
them, and, leaving them in contact with the head, watch the result. If 
the head now moves satisfactorily with every pain, they may be entirely 
withdrawn ; but, so long as there seems a probability of further assistance 
being required, it is better to leave them than to run the risk of having 
again to apply them at a more advanced stage of the labor. If it is a 
case of inertia, or if there is obvious obstruction at the outlet, our efforts 
must be continued at intervals as before ; resting satisfied with a very 
gradual advance, and never (unless under exceptional circumstances, when 
rapid extraction is imperatively demanded) striving for a speedy termi- 
nation of the case, which might endanger the perineum, and the other 
soft structures which nature in normal cases very gradually distends. 

The direction which, in labor, the head naturally takes is always to 
be kept in mind. As it descends, therefore, if it has originally been in 
the cavity when the blades were introduced, the handles are to be carried 
forwards under the arch of the pubis, and, at the moment of birth, are 
to be raised in front of the symphysis. It is at this moment that hurry 
or violence of any kind is apt to lacerate the perineum, so that we 
should, by every means in our power, closely imitate the process by 
which nature so admirably effects the dilatation of this structure. It is 
usual to practise what is called support of the perineum, in forceps as in 
ordinary cases; but in such means, as a preventive of laceration, we 
have, for reasons already stated, no confidence whatever. As the head 
passes from the cavity to the outlet, the natural movement of rotation is 
not to be forgotten. It is not, indeed, necessary that we should attempt 
artificially to produce this rotation. Under the influence of the ordi- 
nary causes, nature will effect it at the proper time, whereas we might 
only do harm by misplaced efforts before that time has arrived. Still, it 
is proper that we should watch the first indications of rotation, and, in 
our subsequent endeavors, "humor" the blades so as in every way to 
encourage it. 

The situation on the sides of the child's head which corresponds to the 
blades varies considerably, and will depend, in some measure, on the 
degree of moulding, or elongation, which may have occurred. When 
successfully applied, so as to obtain the best possible hold, the tips of 
the blades will be found to have passed over the ears, and to have 
grasped the soft parts of the cheek beyond the zygomatic arch. In not 
a few cases, however, and especially in those in which the forceps has 
been used before the head has attained the perineum, they do not reach 
so far, and in these the point attained will be marked by a depression in 
the temporal region above the zygoma. Beyond the depression just men- 



IX OCCTPITO-POSTERIOR POSITIONS. 467 

tioned, the injury inflicted upon the soft parts of the child should be very 
trifling, even in severe cases. A certain amount of discoloration, from 
bruising, is sometimes noticed, but this disappears in the course of a few 
days. 

• In the third and fourth, or occipito-posterior positions, the difficulties 
which we encounter are often much more formidable. These difficulties, 
it is to be remembered, probably depend entirely on the faulty nature of 
the position. Our first attempts, therefore, should be to remedy these 
positions, by promoting the rotation which would bring the occiput for- 
wards. Having failed in our attempts to induce this rotation by the 
fingers, with or without the vectis, in the manner formerly described (see 
Chap. XVIII.), we should always try to effect rotation by the forceps, 
previous to attempting direct extraction. Very special care is here ne- 
cessary, as a moment's consideration will show, to distinguish between 
the two occipito-posterior positions. If, for example, we should mistake 
the third position for the fourth, we would apply our rotating force so as 
to move the occiput from right to left in an attempt to reduce it to a first 
position, with the result, if we moved the head at all, of forcing it in the 
direction of the conjugate diameter, and thus making matters worse, 
instead of better. If, however, we are confident in our diagnosis, we 
have only to remember that third positions rotate naturally into the 
second, and fourth into the first, which at once points to the direction in 
which alone rotatory force can safely be expended. Dr. Tyler Smith 
says that we should rotate during the process of extraction ; but it is 
better that we should, in the first place, attempt simple rotation, and 
then, if that fail, combine rotation with extraction. If we succeed in 
effecting rotation, the case, left to nature, will terminate in the usual 
way. But, should we fail, it will be necessary to extract directly, with- 
out rotation, — a matter often of considerable difficulty. 

In delivering by the forceps, while the head remains in an occipito- 
posterior position, care must be taken to conduct the operation with a 
due regard to the manner in which nature effects delivery in such cases. 
If we attempt to drag the head forwards under the pubic arch, Ave will 
probably fail ; so that we should direct our efforts so as to get the occi- 
put over the perineum, — as it is only in this way that the occipito-mental 
diameter can be released, — and the forehead is then suffered to sweep 
backwards from behind the symphysis. The great danger is rupture of 
the perineum, which, in some instances, it will be almost impossible to 
avoid ; but, when the pelvis is of good size, the difficulties attending de- 
livery in such a position are by no means so great as might be supposed. 
The Long Double-curved Forceps. — Whatever opinion may be enter- 
tained as to the propriety of employing the forceps with a double curve 
in all cases, without exception, we have no doubt that the long forceps, 
as applicable to cases where the head is at or above the brim, can only 
be used with safety when constructed on this principle. The objection 
to the long straight forceps in this situation is pretty obvious, if we 
reflect that extraction, exactly in the axis of the brim, is impossible, as 
the line representing that axis passes through the coccyx, or even the 
lower part of the sacrum. It is not, indeed, until the head has fallen 
well into the cavity, that it may be supposed to occupy a plane the axis 



468 



THE FORCEPS 



of which passes in front of the perineum. Not even with the pelvic 
curve can we pull directly in the axis of the brim, but we are able more 
nearly to approach to what is desiderated, and, what is much more im- 
portant, to do so with comparative safety. If the straight forceps is 
used at the brim, not only do we pull the head too much forwards, but 
we do so to the imminent danger of the perineum, against which the 
shank of the blades is pressed. And, if we overcome the first resistance, 
the widening of the blades as they descend exposes this structure to ever- 
increasing danger as the child descends, for it is not till the head reaches 
the lower third of the cavity that we can bring the handles forwards. 
The risk to the perineum is, no doubt, much lessened, if we use an in- 
strument in which the shanks are 
-^^^* " approximated for some distance, 

so that the curve of the blades 
springs from a point several inches 
from the lock, as in a modification 
of Beatty's forceps, which has been 
very commonly used. 

In the construction of this variety 
of long forceps, bearing in mind 
the rule already laid down, our 
first point is to insure strength 
Avithout clumsiness. There is good 
reason to believe that the neglect 
of this precaution has been the 
cause, in many instances, of the 
instrument slipping again and 
again. There is no necessity for 
the blades, if of proper material, 
to be of great thickness, but the 
handles should always be large, of 
sufficient size, indeed, to be firmly 
grasped by both hands. Endless 
varieties and modifications of the 
long-curved forceps have been de- 
vised, and it is but natural that 
every operator should prefer his 
own. The instrument here shown 
(Fig. 165) is somewhat similar to 
what is known in this country as 
Simpson's forceps, which was 
adapted by him from the pattern 
of that used by Naegele and other 
German accoucheurs. The joints 
are made so loose as to admit of 
very slight lateral motion or overlapping, and below the lock there are 
transverse rests which give more power to the hands ; " the long forceps," 
as Simpson observes, " being only properly used as an instrument of 
traction, not of compression." The length of the instrument which we 
have represented here is sixteen and a half inches, being ten and a half 



Forceps for Application at the Brim. 



DELIVERY BY LONG FORCEPS. 469 

inches from the lock to the tip of the blades, and six inches for the 
handles. The measurements between the blades should be the same as 
those of the medium sized instrument above described, and the fenestrge 
about five and a half inches in length. The instrument is thus, as is be- 
lieved, both longer and of greater strength than those which are generally 
employed by English practitioners. It is, we believe, inferior in effi- 
ciency to none, and, if used with due caution, equal in point of safety to 
any. No one should, however, under any circumstances, take such an 
instrument into his hands without a sense of responsibility much greater 
than attaches to the ordinary operation. 

The long forceps, in the sense in which we employ the term, is ap- 
plicable to cases in which the head w^ill not enter the brim or descend 
beyond the upper part of the cavity. The cases which are held to war- 
rant its employment are chiefly those in which the head is arrested at the 
brim by reason of moderate contraction of the conjugate diameter. 
Great care must therefore be taken, in the first instance, to ascertain the 
degree of deformity, and to make sure that the case is really one in 
which the forceps may be used wdth a reasonable prospect of success ; 
for, if not, nothing can be more irrational than to subject the woman to 
the not inconsiderable risk which attaches to this operation, even under 
the most favorable conditions. When the child is dead, and the estimated 
difficulty in extraction is considerable, most accoucheurs would prefer to 
deliver by craniotomy ; but, if on the contrary, there is evidence of the 
child being alive, nothing can be more repugnant to the feelings than the 
idea of an operation which deliberately destroys a life, and we will 
naturally prefer any procedure which may give the child a chance. To 
yield too far to this inclination would, however, be manifestly wrong, for 
the mere fact of the child's life need not enter into the calculation when 
it is obvious that it must, sooner or later, be sacrificed. Our whole 
attention, in such a case, should be centred in the mother, in whose 
interests, therefore, we should decide upon that operation which is likely 
to subject her to the least possible risk. 

But it is not against craniotomy alone that the long forceps may be 
balanced, for there are cases in which the question for decision is be- 
tween the forceps and turning, as will be better understood when we 
come to consider the conditions under which we have recourse to the 
latter operation. It has been said that the forceps is a " child's opera- 
tion," but we would take a very narrow and improper view of the scope 
of the instrument did we conclude that it was always so, and that it was 
inapplicable in the interests of the mother. The results of craniotomy 
are, according to Churchill, about one maternal death in five, and we 
may be sure that when the head is high in the pelvis the figures w^ill be 
more unfavorable still. Nothing can be more absurd, therefore, than to 
assume that, in so far as the mother is concerned, craniotomy and the 
long forceps stand to each other in the relation of safety and danger ; 
and yet it would almost seem that this was the idea which prompted 
some, even in modern times, to declare in favor of the former. 

The operation by the long forceps is one to which, as a rule, a certain 
degree of difficulty and danger is attached. This arises from the peculiar 
circumstances of the case, as compared with the ordinary forceps opera- 



r 



470 THE FORCEPS. 

tion. There can scarcely be a stronger contrast than between a case re- 
quiriDg the application of the ordinary forceps, when the head lies upon 
the perineum, and is arrested by simple inertia, and one in which a con- 
tracted brim prevents the head from entering the pelvic canal. In the 
one, we have the operation in all its details so thoroughly within our 
control, that we almost cease to look upon it with the slightest apprehen- 
sion. In the other, we are operating comparatively in the dark, and at 
great mechanical disadvantage ; we have to subject, to an extent which 
w^e cannot fully be aware of, delicate textures to violent compression ; 
we have to drag the head through the whole length of the pelvic canal 
instead of merely disengaging it from its lower extremity ; and, finally, 
w^e have to determine between the amount of actual obstruction and the 
degree of justifiable force, with a nicety upon which success or failure 
will depend. Is it, then, to be wondered at that the operation is looked 
upon with apprehension as one beset with difficulties and dangers ? 

While we freely admit that the objections with which delivery by the 
long forceps is beset are in themselves sound, we must, at the same time, 
express our conviction that they have been, to a great extent, exaggerated, 
and that more by British than by Continental and American obstetricians. 
We see no reason to doubt that, when skilfully and warily employed, the 
best results Avill, in many instances, follow from its use — the one essential 
element which, above all others, will contribute to success, being a care- 
ful selection of proper cases. It is now very generally believed, by 
those who have had the greatest experience, that a large proportion of 
the unfortunate results depend upon improper instruments, and especially 
upon the use of such as are deficient in power. The observations which, 
on this point, we have already quoted from Dr. Barnes, apply here with 
peculiar force. Power and control are correlative factors towards the 
attainment of the result Avhich we desire, and if there is a deficiency in 
the former w^e can have but little confidence in the issue of the case. 

[The dread of the operation with the long forceps, spoken of by the 
author, is one which is not shared by American obstetricians. No one 
can doubt that if arrest occurs at the inferior strait or low down in the 
cavity of the pelvis, the application of the forceps is less difficult than 
when the progress of labor is checked with the head well up in the 
cavity, or at the brim. But, even under the latter circumstances, the 
forceps are constantly used in this country, and many prefer them to 
version, even when the head is movable. It should always be remem- 
bered that when skilfully and properly used the instrument cannot 
injure the mother. — P.] 

As regards the mode of application, the long forceps differs in many 
essential particulars from the other. Exceptional cases may no doubt 
occur, in which the forceps is applied at the brim to effect delivery, which 
is called for in consecjuence of inertia, hemorrhage, and the like ; but in 
such cases (in which we may assume the pelvis to be of normal dimen- 
sions) the operation of turning will generally be preferred. Delivery by 
the long forceps may practically be considered as an operation in which 
the head is arrested by reason of contraction of the pelvic brim. Our 
object, then, is not to apply the blades in the opposite oblique diameter 
of the pelvis to that occupied by the child's head, so as to secure their 



DELIVERY BY LONG FORCEPS. 471 

adaptation to the sides of the cranium, but rather to introduce them with 
special reference to the pelvic walls, so as to be sure that each passes 
along the side of the pelvis, and is thus opposite to the other in or near 
the transverse diameter of the brim. When the head is still above the 
brim, it usually occupies, as we have seen, a position which is more 
transverse than oblique, and the effect of conjugate contraction at this 
part is to maintain that position even after the head has actually engaged 
in the brim. Were we here to follow the usual rule, and did w^e succeed 
in applying the blades in that way, their grasp would be in the conjugate 
diameter, and in every effort we would run the risk of subjecting the soft 
parts of the mother to injurious pressure betw^een the blades and the poles 
of the conjugate measurement — the chief danger being posteriorly against 
the projecting sacral promontory. Consequently, we must discard all 
preconceived ideas and rules, and pass the blades in the direction iuAvhich 
there is most room. 

[The discussion of the vexed question, whether the forceps should be 
applied in relation to the pelvis or the child's head, demands more than 
the passing notice given it by the author. Most American authorities 
teach that the forceps should be applied to the sides of the head if it is 
possible to do so. Hodge, Elliot, and others, how^ever, recognize the fact 
that this may be difficult or impossible when the head is transverse at or 
below the superior strait. On account of the danger of wounding the 
bladder and other delicate tissues, they advise that the blades be applied 
obliquely, one over the brow and the other over the opposite side of the 
occiput. Drs. Goodell, A. H. Smith, and Elwood Wilson, of Philadel- 
phia, all assert that the blades should always be applied to the sides of 
the child's head, no matter what may be its position in the pelvis, nor at 
what stage in labor extraction is attempted. An equally radical, but op- 
posite opinion, has been assumed by the author, Barnes, and others, in 
Great Britain, and by German obstetricians in general, wdio assert that 
the position of the head should be practically disregarded and the forceps 
applied in relation to the pelvis. 

It will at once be seen that this is a very important question, not only 
as regards the success which follows the use of the forceps, but also as 
regards the convenience and comfort of the operator. It is manifest if 
the position of the child's head can be safely disregarded, that the for- 
ceps are much more easily introduced. 

In order to decide this question it will be necessary to study the pecu- 
liarities of construction and action of the instruments employed, as well 
as the mechanism of the birth of the head in delayed labor from con- 
traction of the pelvis. In describing the various varieties of forceps 
used in this country, it will be remembered that they were divided into 
two classes, those w^hich are forcible compressors, and those which are 
possessed of but slight compressing power. In the first class are the in- 
struments of Hodge, Robertson, Wallace, and Smith. These are all 
constructed with the idea of developing this force to a considerable de- 
gree. Prof. Hodge, in his lectures and writings, strongly advocated a 
resort to compression in order to diminish tlie size of the child's head, so 
as to bring it through the contracted pelvic diameters. ISTow, adopting 
the rule that the forceps should always be ajDplied to the sides of the head, 



472 THE FORCEPS. 

it is the biparietal diameter Avhich is shortened by this pressure. It is 
an acknowledged fact, also, that in cases of contraction of the brim, the 
head does not enter the pelvis with the biparietal in one of the oblique 
diameters, but in the conjugate of the pelvis. Hodge, Elliot, and others 
agree with Simpson, that it is dangerous to attempt to apply the instrument 
to the sides of the head under these circumstances. Hodge also admits 
the fact that it is often very difficult to effect this when the head is driven 
down into the pelvis in one of the oblique diameters. He admits that 
the introduction of the blades is more difficult under these circumstances 
than when the head is at the superior strait. Dr. Ramsbotham, although 
an advocate for the application of the forceps to the sides of the head, 
acknowledged, in 1862, that he had "for many years been accustomed, 
however low the head may be, to introduce the blades within each ilium, 
because they usually pass up more easily in that direction." 

It is therefore apparent that the highest authorities who advocate the 
cephalic application of the forceps, recognize that the rule is not universal 
in its application, and Ramsbotham may be said to have practically aban- 
doned it. Those who favor the cephalic application assert that unless the 
head is grasped in its biparietal diameter, compression increases rather 
than diminishes the difficulty. It is to be remembered that the advocates 
of this opinion use forceps which are powerful compressors. The blades 
of Smith's, for example, are only two and a quarter inches apart at the 
point w^here the space between them is widest. 

The use of such instruments as these, the editor believes, is based upon 
a false notion of the mechanism of labor in cases of contraction which 
admit the use of the forceps. That compression will diminish the diam- 
eters of the foetal head, no one can doubt, but if flexion is perfect, this 
does not result in flattening of the cranium between the resisting portions 
of the pelvis w^hich grasps it, so much as in elongation of the head, in- 
creasing its fronto-mental diameter, a fact to which Barnes has directed 
attention. Under these circumstances, traction made with a properly 
constructed instrument, applied to the sides of the pelvis, aids the mould- 
ing of the head by supplying the deficient portions of the circle. Thus 
the elongation of the head is more rapidly effected, and the duration of 
labor shortened. 

If flexion is not entirely perfect, the head does not pass the brim of a 
contracted as it does that .of a normal pelvis. It is to be remembered 
that the figure-of-eight pelvis is comparatively rare. In most cases the 
deformity is due to an abnormal prominence of the sacral promontory. 
The anterior margin of the pelvis preserving, as it does, its natural rounded 
contour, would allow the head to pass if it did not meet with resistance 
from the sharp point of the projecting promontory. The result is, as 
Barnes has shown, that in labor under these circumstances, " the promon- 
tory possesses a like importance at the brim or entry of the pelvis to that 
which the symphysis pubis possesses at the outlet. The promontory is a 
turning-point — a centre of revolution of the head, just like the symphysis. 
The curve round the pubis, which Carus described, has its counterpart in 
a curve round the promontory. In ordinary labor, with a well-constructed 
pelvis, the head enters the pelvis, and reaches nearly to the floor without 



DELIVERY BY LONG FORCEPS, 



473 



deviating much from the straight line which represents the axis of the 
brim. Thus it enters its orbit, the circle of Carus, at once. 

" But a projecting promontory, involving, as it does commonly, a 
scooped-out sacrum below, disturbs this course. The promontory must 
be doubled. I pronose to call this curve tlie curve of the false pro mon- 

If the degree of contraction is great, the rounding of the projecting 
base of the sacrum may indent and even fracture the cranium. These 
injuries generally occur just anterior to the ear, or in front of the bi- 
parietal diameter, which is the one that is lessened by applying the for- 
ceps to the sides of the head. 

These facts point to the conclusion that the application of the instru- 
ments in the manner generally recommended, instead of aiding, actually 
interferes with the proper moulding of the head. If the pelvis is large 
enough to allow the child to be born without injury, the application of 
the blade behind the pubis can only interfere with adaptation and descent, 
while the presence of its fellow on the side of the cranium next to the 
sacrum prevents the head from doubling the promontory, by making it 
" a centre of revolution," like that of the symphysis in the later stages 
of labor. In place of the natural moulding, the head is violently com- 
pressed and dragged through the inlet without any regard to the meas- 
ures which nature herself adopts to remedy the results of these errors 
of conformation. Forceps are therefore to be applied in relation to the 
pelvis and not to its contents. They are to be used as tractors, not com- 
pressors. The instruments of Simpson, which are now beginning to be 



Fiar. 166. 




C D, Curve of Abnormal Promontory ; B A, Carus"s Curve. Modified from Barnes. 

used in this country, have a space of three inches between the fenestra. 
Such an instrument is almost useless as a compressor, but as a tractor it 
is eflScient and powerful. In speaking of this subject at the discussion 
at the Obstetrical Society of Philadelphia, in 1872, Dr. W. F. Jenks 
called attention to the fact that "'i\iQ great advantage which results from 
the use of an instrument intended only to supplement a deficient vi% a 



474 THE FORCEPS. 

tergo, is that the mechanism of labor can, and does in most cases, when 
the contraction is not too great, proceed undisturbed, the head rotating 
anteriorly inside the blades. In these cases, where this rotation does not 
take place, we only imitate nature, for in cases of contracted pelvis, when 
the maternal efforts are finally sufficient to effect delivery, Ave find that 
this rotation of the head does not occur until late in the process of mech- 
anism. 

" The fact of rotation of the head occurring within the blades cannot 
admit of any question. Any one who has used an instrument Avhere 
powerful compression is not excited, has had repeated opportunities of 
verifying the fact. The testimony of Brown, Hohl, Scanzoni, Schroe- 
der, and others is full and decisive on this point. That this rotation does 
really take place, and that the operator is not deceived by having, in fact, 
applied the instruments primarily on the sides of the head, is proved by 
the marks of the blades over the brow and behind the ear, the marks 
showing the application of the instrument on the fronto-mastoid diameter 
at the superior strait, where the want of relation between the head and 
pelvis was sufficient to cause the close adaptation of the blades to the head, 
and their pressure into the soft tissues of the scalp, while the position of 
the blades on the sides of the head in its passage through the vulvar out- 
let leaves the fact of rotation beyond doubt." 

The great difficulty in these cases is when the head is driven down be- 
tween the projecting promontory and the brim. Every one knows that 
it is often very difficult to seize it when it is free and movable at the 
superior strait. These difficulties are so great that many competent au- 
thorities practise version in preference to employing the forceps under 
these circumstances. If the head, transverse at the superior strait, is 
tightly compressed in the conjugate, it is much more troublesome to apply 
the forceps to its sides than when it is free at the brim, just as Hodge 
acknowledges that the blades are harder to get in place when the unro- 
tated head is wedged in the cavity, than it is when it is more movable, 
but at the brim. Many assert that it is not possible to apply the forceps 
to the side of the head when it is transverse and nipped between the pro- 
montory and pubis. Indeed, this appears to be the opinion of most au- 
thorities. We will not say that it is impossible to do this, since accoucheurs 
of our acquaintance and of large experience state that they have done it. 
We do not hesitate, however, to condemn the practice as dangerous to the 
mother, without offering any additional advantages to the child, since it 
interferes with the natural mechanism of labor in contracted pelves. Dr. 
Jenks, in the discussion previously alluded to, in speaking of the appli- 
cation of the forceps under these circumstances, says that "in these cases 
the blades will grasp the head, in spite of any efibrts to the contrary, in 
the oblique or fronto-mastoid diameter ; in other words, they are applied 
to the sides of the pelvis, for this terra 'sides of the pelvis' must not, as 
is often the case, be taken to represent mathematically the terminations 
of the transverse diameter, but the space between the ilio-pectineal emi 
nence and the sacro-iliac synchondrosis. It would be well if the term 
'sides of the pelvis' should be abandoned, and the relation of the instru- 
ment to the oblique diameter of the head substituted. The application 



J 



LONG FORCEPS. 



475 



of the instrument in these cases is not then a matter of election, but of 
necessity." — P.] 

The patient may here also lie on her left side ; and there is this advan- 
tage in the double-curved forceps, that there is not the same necessity 
for bringing the hips over the edge of the bed, as from the nature of the 
pelvic curve the handle of the upper blade does not require to be nearly 
so much depressed. The rules given for the introduction of the blades 
in these cases vary considerably. We prefer, as in the case of the 
ordinary forceps, to pass the lower blade first. Some operators, follow- 
ing the advice of Madame Lachapelle, pass this blade along the sacro- 
sciatic ligament ; but the most experienced of modern authorities prefer 
to pass it over the perineum into the hollow of the sacrum, a little to the 
left of the middle line. If the former method be practised, the handle 
must be directed somewhat to the risiht, althou^ih much less so than in 
the case of the straight forceps. If, on the contrarj^, the operator should 
select, as we would recommend, the second process, the blade may be 
directed, as is here shown (Fig. 167), pretty nearly in a horizontal posi- 

Fiff. 167. 




Introduction of Long Pelvic-cuived Forcepg 



tion, into the hollow of the sacrum. That the introduction of the double- 
curved forceps is a more complicated proceeding than the operation pre- 
viously described, no one will dispute ; and this indeed will appear from 
the description of this stage of the process given by Dr. Barnes : "As 
the point of the blade," he says, "must describe a double or compound 
curve — a segment of a helix — in order to travel round the head-globe, 
and at the same time to ascend forwards in the direction of Cams' curve 
so as to reach the brim of the pelvis, the handle rises, goes backwards, 
and partly rotates on its axis. The handle is now carried backvrards and 
downwards to complete the curve of the point around the head-globe, and 
into the left ilium. Slight pressure upon the handle ought to suffice. 
This will impart movement to the blade ; the right direction will be given 
by the relation of the sacrum and head." Dr. Barnes further illustrates 



476 



THE FORCEPS. 



this by the folloAving diagram (Fig. 168), which we have slightly 
modified. 

The actual introduction of the blade is by no means so difficult, nor is it 
a matter of such nicety as the above description would seem to imply. 

Fi^. 168. 




Diagram, showing the various 



in the Introduction of the Long Forceps (Lower Blade). 



The most scrupulous care should in every case be taken in guiding the 
blade by the fingers within the os uteri ; and, when this has been effected 
the mere raising of the handle, after the blade has been so far introduced, 
causes it to glide upwards, unless some obstacle should exist to impede 
its progress. When thus adjusted to the side of the head, the weight of 
the handle will tend to keep it in position, but this will be more certainly 
effected by intrusting it to an assistant, who should hold it back towards 
the perineum to facilitate the introduction of the upper blade. As in the 
case of the other, this blade may also be passed in the direction of the 
hollow of the sacrum, and is carried in front of the lower blade, to the 
right of the middle line. The handle being now depressed and carried 
backwards, its movements direct the blade along the convexity of the 
child's head towards the right ilium ; and, when the movement is com- 
plete, the handles should be in apposition and lock easily. Success in 



LONG FORCEPS. 



477 



this will, however, depend upon the extent and nature of the distortion ; 
but, if the lateral walls of the pelvis are normal as regards their various 
planes, no great difficulty, after a little practice, will be experienced in 
the introduction and adjustment of the blades. The facility with which 
the lock is adjusted may be looked upon, not only as evidence that the 
blades are in contact with opposed surfaces of the head, but also that the 
case is one in which we may hope for a favorable result. But if, on the 
contrary, we do not succeed in introducing and locking the blades after 
one or two attempts carefully conducted, we must abandon the case as 
one unsuitable for the operation. 

[In this country the forceps are generally applied with the woman on 
her back. For this purpose she is to be brought to the side of the bed, 
and if the head is high up in the cavity, or at the brim of the pelvis, the 
buttocks must be well over the edge. The feet may rest on two chairs, 
or they may be supported by assistants. The position is about that in 
which the patient is placed for the performance of the operation of 
lithotomy. 

It has been urged by those who apply the forceps with the woman on 
her side, that changing her position unnecessarily disturbs the patient, 
and that the exertion which she has to make excites and alarms her. 
These objections have but little force. On the other hand, it may be 
urged that the accoucheur can appreciate the relations of the head and 
pelvis more readily when the woman is in the dorsal position. He can 
manipulate more easily both in introducing the blades, and in the last 
stage of the delivery of the head, when it is necessary to carry the handles 
of the instrument well up towards the mother's abdomen. 

Ficr. 169. 




Introduction of the First Blade in the Dorsal Position. 



The mode of introducing the blades when the woman occupies the 
dorsal position does not differ in principle from the same manipulat* 



when the patient is on her side. 



ion 
It is to be remembered, however, that 



478 



THE FORCEPS. 



in this country the long double-curved forceps are generally employed, 
no matter what may be the situation of the head. In order to under- 
stand the movements which are necessary to effect the introduction of 
the instrum.ent, the student should remember that the problem is purely 
mechanical in its nature. He is called upon to grasp an oval body in a 
curved canal with an instrument which has two curves, one corresponding 
to the body to be seized, and the other to the passage in which it lies. 
In consequence of this he has to execute two movements at the same 
time. Whatever may be the stage of labor at which arrest occurs, the 
operator, having prepared his instrument, introduces that blade of the 
forceps first which will be next the posterior commissure of the vulva, 
when the two blades are applied and locked (Clarke). It is always the 
blade which goes to the left side of the pelvis that occupies this position. 
It is to be lightly seized with the left hand, the handle being elevated 
and carried to the right groin until the extremity of the blade is parallel 
wdth the lips of the vulva. The fingers of the right hand having been 
inserted into the vagina, the blade is now passed along these as a guide 
by gently depressing the handle, and at the same time carrying it in- 
wards or towards the median line of the mother. The instrument is 
therefore introduced by a compound movement downwards and inwards, 
which leaves the lock projecting almost directly upwards, or a little 
towards the left side. The blade may now be supported by an assistant, 
or not, as may be necessary. The opposite branch is now seized in the 
right hand, while the fingers of the left are passed into the vagina to act 
as a guide. The handle is to be elevated and carried towards the left 
groin, until the extremity of the blade becomes parallel with the vulvar 
orifice, when the introduction commences. 

Fig. 170. 




Introduction of the Second Blade in the Dorsal Position. 



The handle is now depressed, and at the same time carried towards 
the right side, or the median line. This compound movement elevates 
the blade in the pelvis, and at the same time carries it around the foetal 



LONG FORCEPS APPLIED. 



479 



head, so that the handle of the right branch is brought parallel with its 
fellow, and the articular surfaces are opposed to each other, and locking 
is readily effected. 

If the articulating surfaces of the lock are not directly opposed to 
each other, the handles should be carried well back towards the perineum, 
when the difficulty in locking is often overcome at once. 

If this does not follow, it may be proper to pass the fingers of one 
hand into the vagina, and by careful pressure upon one or the other 
margin of the blade, as indicated, aided by gentle manipulations of the 
handles, to so alter the position of the blades that locking can be effected. 
If this is not accomplished without the exertion of much force, the instru- 
ment should be removed and reapplied. 

Many American obstetric authors and teachers who assert that the 
forceps should always be applied to the sides of the child's head, give 
special rules for the introduction of the instrument in each position of the 
head. As in this work it is recommended that the blades be introduced 

Fiff. 171. 




Instruments Introduced and Locked in the Dorsal Position, 

in relation to the sides of the pelvis, the student is referred to the 
writings of those wdio advocate opposite opinions for a description of the 
various and complex manipulations by which the blades are brought into 
relation with the sides of the head. — P.] 

It is assumed by many writers that the blades, when thus introduced, 
correspond to the antero-posterior diameter of the head. It is not so, 
however. The head, indeed, very generally occupies the transverse 
diameter of the pelvis, but the tendency of the blades is to adapt them- 
selves to one or other oblique diameter, as has been shown by Simpson. 
This has been conclusively established by examination of the head, after 
delivery by this process, when it is found that ,^ne blade has passed be- 
hind the ear, and the other has reached over the frontal bone on the 
opposite side, and has been applied over or in the immediate neighbor- 
hood of the orbit, as is indicated in Fig. 172. 

The forceps being thus applied, the next step in the process is an 
attempt at extraction. Remembering the power which we possess in so 



480 



THE FORCEPS. 



formidable an instrument as this, we must, in the first place, exercise 
great caution in the matter of compression ; and this point is all the more 
necessary, as the handles will be found to gape more than usual, owing 
to the length of the cranial diameter which is between the blades. 

Ficr. 172. 




Long Forceps Applied. 

Moderate compression is all that is necessary to maintain the position of 
the forceps when well applied, for we know that it is not by manual com- 
pression only, but also by compression of the blades by the walls of the 
natural passage, that their grasp is sustained. The handles are to be 
seized by both hands and steady traction practised, the direction at first 
being somewhat backwards. As in the case of the ordinary forceps, the 
traction must not be continuous, but in aid of present, or in imitation of 
absent pains ; and, at the same time, we combine with mere pulling effort 
a moderate degree of the swaying or double-lever action, taking great 
care not to injure the perineum.^ 

The thorough control which the size of the handles gives us over the 
instrument enables us to perceive with greater accuracy whether or not 
the head can be dislodged by such efforts as we are justified in making. 
This may be more exactly ascertained by passing the finger from time to 
time in the direction of the head, when the descent of the occiput or the 



' An attempt has been made by Professor Tarnier to modify tbe forceps so as to pull 
more directfy in the axis of the brim, and at the same time to protect the perineum, 
and to a\^oid injurious pressure in the direction of the pubic symphysis. ■ This instru- 
ment, in the construction of wliich great mechanical ingenuity is displayed, is sigmoid 
in shape, from the addition of a special perineal carve. The chief objection to 
Tarnier's forceps is that it is too complicated in its construction to be generally use- 
ful, and although several modifications have been suggested with the view of sim- 
plifying tlie construction of the handles, the same objection also applies to them, 
although, perhaps, in a lesser degree. For a full description of Tarnier's instrument, 
see British Medical Journal, May 26, 1877. 



APPLICATION IN FACE PRESENTATION. 481' 

rotation of the sagittal suture towards the conjugate diameter may afford 
clear evidence that the head is making progress. As it descends, the 
handles of the forceps will be observed to rotate, and in some cases it 
may be possible to assist the rotation. When this stage has been reached, 
it will be proper to carry the handles more forwards, and to pull rather 
downwards than backwards, following the curved axis of the pelvic 
cavity. Finally, the operator must carry the handles forwards and up- 
wards in front of the symphysis ; and, in order that this may be effected 
with ease, the right thigh should be raised by the nurse, or the patient 
may be laid on her back so as to permit the handles to move upwards in 
the direction of the umbilicus. The operator must, however, beware of 
moving the handles prematurely in this direction, as he may thereby do 
mischief. And there is another danger which he must specially avoid, 
viz., the ploughing up of the perineum by the blade which, in conse- 
quence of the rotation, is now turned against it. This may, no doubt, be 
avoided by disarticulation of the blades as the head approaches the out- 
let ; but, as it is often necessary to continue the traction to the last, 
extreme caution must at this stage be observed. In nothing should we 
be more particular than in the slowness and deliberation with which we 
conduct the various stages of this operation ; for, in all the details, the 
more closely we are enabled to imitate nature, the more likely is the 
operation to have a successful result. 

It may be necessary to apply the forceps in the treatment of presenta- 
tion of the face. So long as the chin is turned forwards, as it is in what 
we have described as the third and fourth varieties, the case is in all 
respects a normal one, and should be left to nature. But inertia, and the 
otlier causes which call for the forceps in a cranial position, may, in such 
a case, exist also, demanding instrumental assistance. The application 
of the forceps is here in no respect more difficult, nor more serious, than 
when the vault of the cranium is the presenting part, the chin being 
regarded throughout as strictly analogous to the occiput in the mechanism 
and direction of its birth. The rules, therefore, which have been laid 
down for the application of the forceps in occipito-anterior positions of 
the vertex, may here be adopted, r)iiitatis mntmidis, with equal pro- 
priety. It is very different when we have to deal with a mento-posterior 
position of the face, which is by far the most unfavorable of all possible 
presentations of the cephalic extremity. Such is, as we have seen, the 
probable position of the majority of face cases at the beginning of labor, 
rotation of the chin forwards occurring as the head descends. 

But the cases to which we refer are when this rotation fails, and when 
the head descends into the cavity in its original position with reference 
to the pelvis. Two methods of treatment have here been suggested, and 
have apparently been practised with success ; these being application of 
extracting force over the occiput, so as to convert it into an ordinary 
cranial position, and rotation by the forceps, so as to convert it into 
a mento-anterior position. Smellie, Cazeaux, and others have succeeded 
by the first method ; but that which seems most practicable, at least from 
a theoretical point of view, is rotation, a manoeuvre which, for obvious 
reasons, can only be practised with the straight forceps. By the latter 
means, rectification has in many instances been eflected, so as to insure a 
31 



482 



THE FORCEPS. 



favorable termination of the labor ; and it would be proper in every such 
case to make the attempt ; but, if we fail, and the symptoms indicate 
approaching exhaustion, or are otherwise such as are held to imply a 
necessity for speedy delivery, we have no resource remaining but crani- 
otomy. If, in a deformed pelvis, the face presents at the brim, turning 
is better than the long forceps in most cases ; and if the chin is back- 
wards, there can be no doubt about it. 

In all cases of pelvic presentation, and in the last stage of delivery by 
podalic version, we have the forceps ready, lest any difficulty should 

arise in regard to the extraction of 
Fig. 173. the head by the ordinary process. 

The chin, in such cases, being 
almost always turned backwards 
towards the perineum, the blades 
are passed in front of the sternum 
of the child, over the chin and 
sides of the head. The body of 
the child is then to be carried up- 
wards, towards the abdomen of the 
W /// %\ IF 'W mother, by an assistant, when, if 

I // mi i If *^^® handles of the forceps are 

made to follow it in the same di- 
rection, combining the movement 
with a moderate amount of traction, 
the head will usually be extracted 
without difficulty. This is an ope- 
ration in which delivery must often 
be effected with greater precipi- 
tancy than usual, — as, for exam- 
ple, when twitching of the limbs 
shows that asphyxia is impending. 
There are other comparatively rare 
instances, in which the operation is 
not effected with such ease. We 
may encounter cases, for example, 
in which the trunk being born, the face has not rotated backwards. 
These are the instances in which Madame Lachapelle advises us to rotate 
the face by the finger before extracting it ; but, if this cannot easily be 
done, it will be better to adopt the plan suggested by Velpeau, and en- 
deavor to drag down the occiput beyond the edge of the perineum, and 
deliver the head by a movement of extension, instead of, as is usual, by 
the ordinary one of flexion. There are cases, also, in which the head, 
after turning or in breech presentation, is arrested at the brim in conse- 
quence of deformity, when it might be possible to deliver by applying the 
forceps along the sides of the pelvis; and there are instances, rarer still, 
in which the head is separated, and left behind in the cavity of the 
uterus, where we must attempt extraction by the forceps, so adjustmg 
the blades as to prevent the possibility of the occipito-mental diameter 
being thrown across the pelvis. 

The difficulties which, under special circumstances, attend the mtro- 




Ziegler's Forceps. 



VARIETIES. 



483 



duction of the forceps have given rise to innumerable modifications of 
the instrument, none of them (with a few exceptions, such as the forceps 
of Mondotte, in which the blades do not cross) affecting the general 
principles upon which the instrument is constructed. To one or two only 
of the more important of these we may call attention. Dr. Ziegler of 
Edinburgh has recommended a forceps (Fig. 173) of which the blades 
are straight, but dissimilar. The fenestra of one blade is carried down 
to the handle, and in introducing the instrument, the elongated fenestra 
is slipped over the handle of the other blade, which has been previously 
passed, and which serves, therefore, as a guide for the adjustment of the 
other. What is described in the Obstetrical Society' § Catalogue as Mr. 
Philip Harper's forceps seems, both in principle and in construction, to 
be identical with Dr. Ziegler' s. 

Dr. Radford, again, has invented an instrument (Fig. 174), of which 
the blades are of unequal length, and in which there is a reversed posi- 
tion of the lock. This ranks as a long straight forceps, and is designed 
by the inventor for application to the head when it is arrested at the 
brim, the long blade being passed over the face, and the short one over 



Fiff. 174. 



Fi-. 175. 





Eadford's Forceps. 



Assalini's Forceps. 



the occiput. The opening formed by the curve in the shank of each 
blade is for the purpose of passing a handkerchief through, and will 
enable the practitioner, in addition to his hold of the handles, to use very 
powerful and effective extracting force. 



484 THE FORCEPS. 

Although the English lock is justly looked upon as one of the most 
important points in the construction of the forceps, there is no doubt that 
a most efficient instrument may also be constructed in which the lock is 
at the end of the instrument. This is the case in Mondotte's forceps 
already mentioned ; and also in Assalini's forceps (Fig. 175) in which 
the hand grasping the centre of the instrument keeps up a steady pres- 
sure, proportionate to the amount of force which is being employed, and 
over which the operator has a most sensitive and efficient control. Some, 
even in England, prefer it to our ordinary instruments. 

To these we might add numerous varieties, which exhibit infinite pecu- 
liarities, and which differ from the familiar standards in the nature of the 
curves, pelvic or cranial, the length of the fenestras, the width of the 
blades, and the arrangement of the shanks, handles, and locks. To de- 
scribe even a tithe of these would carry us beyond our prescribed limits, 
and would serve no useful purpose. 

In expressing a preference for the straight over the double-curved 
forceps, in all ordinary cases, we must not be supposed dogmatically to 
condemn the latter instrument in what are generally called short forceps 
operations, or, indeed, in any other, save those in which we use the for- 
ceps for the purpose of effecting rotation. The authority of those who 
have pronounced more or less emphatically in its favor is of too great 
weight to be overlooked. We are inclined, more particularl}^ to admit 
the force of Simpson's observation, that it is well for the operator to 
accustom himself to the use of one kind of instrument only, as a strong 
argument in favor of the pelvic curve ; but, on the other hand, we enter- 
tain personally a strong conviction that the straight forceps, while it can 
effect, below the upper third of the pelvic cavity, everything which the 
other can achieve, is essentially easier of application by beginners, as it 
is, undoubtedly, simpler in construction than its rival. When once its 
special difficulties are overcome, we cannot doubt, however, that in hands 
familiar to its use, the double-curved forceps fulfils all the indications of 
a safe and efficient extractor. 

We would conclude this chapter with a single word of caution to the 
young practitioner who has overcome the preliminary difficulties, and who 
has attained a certain amount of confidence and skill in the use of the 
instrument. It is to beware lest this should lead him to a too frequent 
and unnecessary application of it. Above all, let him remember, that 
no mere question of time, or of his own convenience, can ever be a suffi- 
cient warrant for operative interference. No operation is without risk, 
and nothing, therefore, short of a conscientious conviction that he is about 
to act in the interests of the mother or the child, can ever absolve him from 
the responsibility which attaches to him in virtue of the position which 
he occupies. But, on the other hand, he must no less carefully avoid the 
error of excessive timidity, which may deter him from assisting his patient 
in many a case where prolonged and needless suffering means increase in 
danger to her and to her child. 



MAJ 



THE VECTIS. 485 



CHAPTEK XXX. 

THE YECTIS; FILLET; BLUNT HOOK; Etc.: DECAPITATION. 

Discoi-ery of the Vectis hy Roonhuyscn : Mode of Using the Vectis: Cases to 
which it may be Applied. — The Fillet ; a Contrivance of Ancient Origin : 
Applicable chiefly to Breech Cases. — The Blunt Hook. — The Crotchet : 
Precautions necessary in the Use of the Crotchet: The Gudrded Crotchet: 
Use of two Crotchets. — Decapitation ; Various Instruments for : Descrip- 
tion of the Operation: Extraction of the Trunk: Subsequent Extraction of 
the Head by the Various Methods of the Forceps., Crotchet., or Cephaloiribe. 

About the same time that the discovery of the Chamberlens was gradu- 
ally brought to light and introduced into practice in this country, the 
Vectis or Lever Avas being used for the delivery of women in Holland by 
Roonhuysen. The frequent sacrifice of infant life — which was rendered 
necessary in cases of difficult or obstructed labor — was no doubt the cause 
which, in both cases, turned the attention of the inventors to the subject, 
with the earnest desire to devise any means whereby the crotchet and 
perforator might be superseded by some contrivance which would deliver 
the woman without destroying her child. The discovery of Roonhuysen, 
although of much less importance than that of Chamberlen, was an in- 
estimable advantage in practice ; and, by the rude instrument contrived 
by the Dutch accoucheur, many successful operations Avere performed by 
himself, his son, Ruysch, and some others to whom the secret had been 
communicated. This original lever was of the simplest possible construc- 
tion, and consisted of a flat piece of iron, bent at each end into a slight 
curve, and covered with soft leather to protect the parts. Tlie secret of 
the lever was eventually purchased from those to whom it had been 
handed down after Roonhuysen's death, by two Dutch physicians, Vis- 
scher and Van den Poll, whose names are more worthy of being recorded 
than those of the inventors, as they jointly paid the sum of 5000 livres 
in order that they might impart to the world a secret which should never 
have been withheld. As the knowledge spread, the simple contrivance 
of the originators became altered and modified, until it resulted in the 
vectis of the present day. 

One is apt to suppose that, as the Vectis is now seldom used, it has 
been discarded as a worthless instrument. So far, however, from this 
being the case, the vectis must always be looked upon as an extractor of 
considerable power and efficiency, and the sole reason for the neglect into 
which it has now fallen, is simply because it has been utterly thrown into 
the shade by the forceps. There are, moreover, even in the present day, 
practitioners of great experience who occasionally use the vectis in cer- 



486 



THE VECTIS, 



tain cases in preference to the more familiar instrument. The modern 
vectis has, in its general appearance, a certain resemblance to a single 
blade of the forceps, and, like the latter, varies greatly in 
Fig. 176. its shape, handle, and fenestra ; but more particularly in the 
curve which is given to it with a view to efficient adaptation 
to the head of the child. The variety which is here repre- 
sented is one of the best known of the numerous modifica- 
tions of Roonhuysen's lever. It is sometimes furnished with 
a hinge between the handle and the blade, — a principle which 
has also been applied by some to the forceps, with the view 
of facilitating the introduction of the upper blade. Such an 
arrangement is, however, quite unnecessary, if the woman 
is placed in the proper position on her left side, and her hips 
are brought quite over the edge of the bed, when it may be 
introduced without difficulty with reference to any position 
of the head, or any part of the circumference of the pelvic 
wall. 

If we had not at our command a safer and more perfect 
agent in the forceps, there can be no doubt that the vectis 
would be an instrument of every-day use for the extraction 
of the child, whether employed as a lever or a tractor. 
These two ideas have, manifestly, been the guiding princi- 
ples upon which suggestions as to the modification of the 
instrument have been based ; when the idea of leverage has 
predominated, the curve has been slight ; whereas, when 
traction has been the object, the curve has been greater, so 
as to secure, for this purpose, a firmer hold of the head. 
No efficient action of the vectis can, however., be produced, 
unless the principle of a simple lever is more or less brought into play ; 
for, even if we admit it as possible that it may act as a tractor, it can 
obviously act only upon the end of a cranial diameter, which latter be- 
comes a lever, the fulcrum of which is at the other pole of the diameter 
thus acted upon. But its efficient action is scarcely compatible with this 
idea, as it will generally be found necessary so to use it as to make the 
blade itself a lever, the fulcrum of which must be found in some part of the 
pelvic wall. This, in fact, is the great objection to the vectis, when we 
compare it with the forceps, where the fulcrum of each blade is the lock. 
It may no doubt be possible, in the case of the single lever, to protect 
the soft parts by interposing a finger where the force is brought to bear 
upon the fulcrum, and we may be sure that this is the manner in which 
Roonhuysen and his followers operated ; but still, even under the most 
favorable circumstances, the danger which arises from such a plan of ac- 
tion must be viewed as considerable, and in direct proportion to the me- 
chanical force employed. 

When the vectis is used with the view of facilitating delivery in cases 
of cranial presentation, it is essential, in the first place, that the position 
of the head be accurately ascertained ; and, further, that the operation 
should be conducted with a perfect knowledge and appreciation of the 
laws upon which the natural phenomena of parturition depend: the 
object being chiefly, therefore, to bring the occiput forwards under the 



The Vectis. 



THE VECTIS. 487 

arch of the pubis. If we should thus succeed, by pulling down the oc- 
ciput, in increasing the occipito-frontal obliquity of the head, it is clear 
that we are, at the same time, closely imitating the process by which 
nature manages the descent of the head. This may, if the uterus is 
acting efficiently, be all that is required ; and, in any case, it advances 
matters a stage. But, in cases of unusual difficulty or absolute inertia, 
little ultimate good will result if we stop short at this stage of the ope- 
ration so that we can only act effectively by bringing our force to bear 
against the two ends alternately of the occipito-frontal diameter. So 
soon, therefore, as we have succeeded in causing the occiput to advance, 
the vectis is to be withdrawn and adjusted to the frontal pole ; and by 
thus acting, now on the occiput and again on the forehead, we may cer- 
tainly and steadily cause the head to advance in the direction of the out- 
let. A blade which is sharply curved will, no doubt, take a firnjer hold 
of the part to which it is applied, but this advantage is probably more 
than counterbalanced by an increased difficulty in its introduction. It is 
for this reason that a more gentle or wider curve has been generally pre- 
ferred, which, while permitting of easier introduction, makes it more 
necessary that the blade itself should be used as a lever ; and, indeed some, 
have gone so far as to say that no vectis can possibly be better than a 
single blade of the straight forceps. 

It would appear that the cases in which the modern accouche ar may 
with advantage have recourse to the vectis, are those in which his primary 
object is to act upon the occipito-frontal diameter of the head. Should 
it seem, therefore, that all that is necessary is to insure the descent of 
the occiput, it is possible that delivery may thus be effected with even 
more safety than by the forceps, where the action bears upon the poles 
of the transverse diameter. Contingencies may also arise, in the course 
of many operations in midwifery, in which the operator might avail him- 
self of the vectis if it were at hand ; but it is probable that in no instance 
is the vectis more applicable than when we wish to correct malposition of 
the vertex. The natural process, by which occipito-posterior positions of 
the vertex terminate by rotation, has already been fully described ; and 
it has also been observed that an essential condition to such rotation is 
the descent of the occiput, along the posterior pelvic wall, while the fore- 
head remains high in the direction of that cotyloid cavity to which it is 
turned. In proportion, therefore, as the forehead descends (^fronto- 
cotyloid position of West) along the anterior wall, the more do we des- 
pair of natural rotation, and look with apprehension to the probability of 
a tedious labor, or a birth with the forehead to the pubis. Much may, 
as we have shown, be done by the fingers of the operator directed against 
the frontal end of the occipito-frontal diameter ; and, indeed, while pro- 
pulsive effort exists, nothing is so likely as this to encourage descent of 
the occiput. But when this procedure fails, we have in the vectis a 
powerful auxiliary, which we may pass over the occiput ; and, thus, by 
pulling the occiput down and pressing the forehead up, we act simul- 
taneously upon the two poles of the long diameter, in restoring or main- 
taining that position of the head in which alone nature effects rotation. 
We may even conceive it possible, that, by a similar mode of procedure, 
we might convert by this instrument a face presentation into one of the 



488 



THE FILLET. 



vertex, by producing a rotation of the head on its transverse axis. We 
may assume, however, as a matter of fact, that, with rare exceptions, the 
vectis, although a powerful instrument, is completely superseded by the 
forceps — by which can be effected more speedily and more safely, almost 
all that the vectis can accomplish. 

The Fillet (laqueus) is probably the most ancient of all the instru- 
ments used in obstetrics with the view of extracting a living child. In 
its simplest form, it is nothing more than a loop or noose, which may be 
variously adjusted so as to facilitate the delivery of the child. It has 
been constructed, according to Ramsbotham, " of a strip of strong cloth, 
silk, or leather, forming into a running noose, and was sometimes sewn 
up like an eel-skin, open at both ends, to admit the introduction of a 
piece of whalebone, cane, or wire, throughout its entire length, by which 
its application might be facilitated. It was intended to be introduced 
over the head in whatever way was most easily ac- 
complished ; and, this done, the cane was to be with- 
drawn, the loop tightened, and extraction was to be 
effected by main force." Such an instrument is, in as 
far as cranial presentations are concerned, so mani- 
festly inferior to the forceps, that we can scarcely 
wonder that it has so completely fallen into disuse as 
not even to be mentioned in many of the best works 
on obstetrics. Some modern authorities have, how- 
ever, to some extent, approved of the principle upon 
which it is constructed, and have directed their in- 
genuity to the manufacture of a more perfect instru- 
ment, of which the "whalebone fillet" (Fig. 177) is 
the most familiar illustration. Its length is about ten 
inches, the loop being seven inches and a half, and its 
extreme width three inches and a half. In its appli- 
cation, the loop is to be passed over the occiput, and 
steady traction exercised, when, if this is not sufficient, 
it may be adjusted over the forehead or chin, thus 
alternating the extracting force between the frontal 
and occipital poles of the long diameter of the head, in 
a manner somewhat similar to what is practised in the 
case of the vectis. 
The fillet may still be usefully employed in the management of breech 
presentations, when delivery is arrested either by inertia or disproportion 
of the parts. Some have, under such circumstances, insisted that the 
forceps may be used ; but the experience of the great majority of prac- 
titioners has shown that we cannot depend upon that instrument, which is 
essentially constructed for application to the cranium. A most efficient 
means of extraction is, no doubt, afforded here by the blunt hook, but the 
objection to that instrument, as has already been stated, is the injury 
which may, by its use, be inflicted upon the groin and genital organs of 
the child. The fillet may, however, be substituted, and employed both 
with safety and efficiency. A simple loop or noose, as was the nature 
of the original fillet, is, in such instances, to be passed over the flexure 
of the thighs, by means of the fingers, an elastic catheter, or (as has 




Whalebone Fillet. 



THE BLUNT HOOK. 



489 



Fio:. 178. 



been suggested) the instrument which was designed bj Bellocq for 
plugging the posterior nares. Nothing serves the purpose better than a 
simple skein of worsted, one end of which is introduced in this way, and 
the other extremity then passed through it so as to form a running noose. 
This noose may, again, be adjusted so as to direct the extracting force 
in the proper manner ; and, as our object generally will be to pull down 
that hip which is turned forwards in the pelvis, in advance of the other, 
the noose should therefore be placed nearly over the anterior ischial 
tuberosity. 

The Blunt Hook (Fig. 178), which is here shown, is also an instru- 
ment of ancient date. It has been recommended in cases of obstructed 
breech delivery ; but the danger of wounding the soft parts of the child 
which it entails, is now very properly held to be such a serious objection 
to its use, that it has been entirely discarded in cases where there re- 
mains a possibility of the child being alive. In all cases in which the 
child is ascertained to be dead, the blunt hook may be used 
without hesitation ; and, in these cases, it is a powerful 
auxiliary to many of the more important operations of mid- 
wifery. It is, however, less an instrument adapted to any 
special operation, or operations, than one which may be use 
ful in a hundred different ways, while we are attempting to 
extract the child in cases of unusual difficulty. It acts most 
powerfully when hooked into the flexure of a joint. In this 
way, as we have seen, powerful extracting force may be 
brought to bear, when the breech presents, by passing it 
over the groin ; and, in like manner, in cephalic presenta- 
tions, the shoulder may be made to advance by tractile effort 
of a similar kind brought to bear upon the axilla. But while 
these are, perhaps, the circumstances under which the blunt 
hook is most frequently and usefully employed, it gives no 
idea of the real scope of the instrument. This, indeed, em- 
braces points in the detail of many of the chief operations of 
midwifery ; and, in the forcible extraction of the child, after 
the performance of craniotomy, or embryulcia, the hook is 
almost indispensable. Its advantage, as compared with the 
crotchet, is that, as there is no necessary laceration attendant 
upon its employment, it is not absolutely unsuitable for the 
delivery of a living child ; and, besides, that being blunt, 
there is not, should it chance to slip, the same risk to the 
maternal parts. 

The Crotchet (Fig. 179) was described by Hippocrates, more fully by 
^tius, and is alluded to more or less distinctly by all the ancient writers 
on midwifery. It is, like the instrument just described, a hook; but it 
differs essentially in this, that it is always sharpened, so as to pierce the 
tissues, and thus secure a better hold. In its nature, then, the crotchet 
is an appliance which can never be used when we have any hope, how- 
ever remote, of saving the life of the child. The introduction and fixing 
of the instrument is a matter of little or no difficulty, nor is it attended 
with any danger to speak of, as the sharpened portion, being the point 
of the hook, is turned downwards. But, so soon as the direction is re- 



490 



THE CROTCHET, 



versed, and we attempt extraction, the crotcbet becomes, in careless and 
inexperienced hands, a highly dangerous implement. In all cases, there- 
fore, in which a sufficient hold can be had, we will, as a matter of course, 
prefer the blunt hook : but, when it is necessary to act upon flat sur- 
faces, the blunt hook is worthless, and we are obliged to have recourse to 
an instrument which may penetrate, and thus be fixed upon any surface 
to which it is applied. The nature of the crotchet renders, however, the 
maintenance of its grip upon soft tissues extremely preca- 
Fig. 179. rious, and any violent effort at extraction can scarcely fail to 
cause extensive laceration, which, in its turn, permits of the 
sudden detachment of the instrument from the point at which 
it has been fixed to the foetal tissues, and possible laceration 
of the maternal parts. 

Every practical accoucheur knows that no confidence what- 
ever can be placed in the instrument as a tractor, unless we 
can fix it in some unyielding part of the bony structures, 
upon which alone we can safely bring anything like efficient 
effort to bear. But, even this is far from safe ; for, under 
the influence of powerful effort, the crotchet may at any mo- 
ment, even when it is apparently well fixed, break suddenly 
from its attachment. This is, in fact, the special danger of 
the crotchet and the great objection to its use, as by such an 
accident the maternal structures may, in a moment, be se- 
riously, or even fatally injured. It is on this account that 
no sound practitioner will ever use the crotchet without taking 
great pains to guard against the result which may possibly 
ensue ; and he therefore invariably uses the finger of one 
hand as a guard to the crotchet, so that, if it should slip, the 
maternal parts are efficiently protected. An instrument called 
the " guarded" crotchet, in which a spoon-shaped blade is 
substituted for the fingers, as a guard is, as we shall find (see 
Crotchet. Fig. 187), occasioually used at a certain stage of the opera- 
tion of craniotomy. 
While we thus admit the full force of the objections which exist to the 
use of the crotchet, it must be confessed that, in cases of great difficulty, 
it is a valuable, and almost indispensable aid. The point of greatest 
importance is to secure for it a firm and unyielding attachment, so that it 
is usual to try to fix it in the orbit or mouth, or elsewhere in the same 
reo-ion, so as to maintain an efficient hold upon the irregular bones of the 
face ; and, in those instances in which it is passed within the cranium, or 
any of the other hollow cavities of the body, the same principle guides 
our action, so that we may find ourselves at one time fixing it in the 
foramen magnum, and at another attaching it to the spinal column, or the 
pelvic brim. 

The nature of the crotchet is such that it can operate upon one point 
only of the circumference of the head, or other presenting part. If we 
act, therefore, in a cranial presentation, in this manner upon the orbit, 
we run the risk of dragging down the forehead by a movement of the 
head on its transverse axis, without securing any actual advantage, and 
with the possibility, if the chin be backwards, of making matters worse. 



DECAPITATION. 491 

^tius, in one of the most interesting passages of his obstetric works, 
recommends that we should operate by two crotchets, applied at the sides 
of the pelvis, to opposite surfaces of the child's head, and then pull down- 
wards, in order that the traction may be equal, and in the direction of the 
resultant of the two forces (^ad neutram partem decliiians) . Had he but 
thought of the possibility of applying the same principle to the delivery 
of the living; child, he would almost inevitably have discovered the for- 
ceps. But, as in the case of Hippocrates and the olive, such speculations 
are perhaps more interesting than instructive. The hint here given, as 
to the combined action of two crotchets, is not to be despised, as there 
are certainly cases in practice in which the principle indicated might use- 
fully be adopted ; and this, in fact, was recommended and practised by 
Dr. Davis. In so far as cranial presentations are concerned in which the 
forceps fails, or in which the use of that instrument is contra-indicated, 
no good can possibly result, except under peculiar circumstances, from 
the use of the crotchet, until we have already diminished the head by 
perforation of the cranium, and extraction of its contents. 

Decapitation. — An instrument closely resembling, in shape and general 
appearance, the blunt hook, but which is usually sharp within the curve, 
has been used with success in the treatment of those difficult cases of 
transverse presentation in which the ordinary methods of treatment have 
failed. This operation simply consists in abridging the long diameter of 
the child by a section made at the neck. It is described by Celsus, and 
by many writers subsequently ; but, with the exception of Davis, Rams- 
botham, and, more recently, Barnes, the subject has not received that 
attention in this country which it seems obviously to merit. It seems to 
us advisable, therefore, that we should in this place describe the opera- 
tion somewhat in detail. This mode of procedure is chiefly applicable 
to those instances in which we have to deal, either with a neglected case 
of shoulder presentation, where the body of the child is partly impacted, 
or is so tightly embraced by the uterus as to render turning impractica- 
ble ; or with a case in which the difficulty arises mainly from pelvic dis- 
tortion, complicated with a transverse position of the child. 

The form of hook already described is that which is best known in this 
country under the name of Ramsbotham's hook ; but a number of other 
instruments, more or less resembling this, as well as some of a different 
construction, have been recommended. Among the latter may be men- 
tioned a contrivance which consists of a strong cord, which is to be passed 
round the neck, and then, by a saw motion, is carried to and fro by means 
of cross handles at its extremities, until the head is severed. It is pro- 
bable that a modification of the wire-rope eoraseur might be advantage- 
ously used for the same purpose, but the difficulty in such cases would 
probably be the passing of the rope around the neck. It would appear 
that, with the ordinary instrument, a cutting surface is by no means ab- 
solutely essential, as some have succeeded by means of the ordinary blunt 
hook. The operation of decapitation by Ramsbotham's hook or Braun's 
'' decollator," is described by Dr. Barnes as consisting of three stages. 
The first stage is the application of the decapitator and the bisection of 
the neck ; the second is the extraction of the trunk ; the third, the ex- 
traction of the head. 



492 DECAPITATION. 

The first point to be accurately ascertained is the position of the body 
of the child, whether dorso-anterior or dorso-posterior. This being de- 
termined, in the manner already described, by an observation of the hand 
of the foetus, and the woman having been placed in the ordinary obstetric 
position, or on her back, the arm of the child is to be firmly pulled down- 
wards, so as to bring the neck, as far as is practicable, within the reach 
of the operator. The arm is then to be intrusted to an assistant, whose 
duty it is to maintain the position by steady and moderate traction. The 
bladder — ani, if it be necessary, the rectum — are now to be emptied of 
their contents, and the hands and hook smeared with lard or oil. The 
fingers of one hand — right or left, according to the position — are then 
gradually insinuated in a direction corresponding to the anterior surface 
of the child, so as to reach the front of the neck. With the other hand 
the operator then introduces the hook, ''laying flat," says Barnes, "be- 
tween the wall of the vagina and pelvis and the child's back, until the 
beak has advanced far enough to be turned over the neck. The beak 
will be received, guided, and adjusted by the fingers of the left (opposite) 
hand. The instrument being in situ, whilst cutting or breaking through 
the neck, it is still desirable to keep up traction on the prolapsed arm. 
In using Ramsbotham's hook, a sawing motion must be executed, care- 
fully regulating your action by aid of the fingers applied to the beak. If 
Braun's decollator be used, the movement employed is rotatory, from 
right to left, and at the same time, of course, tractile. The instrument 
crushes or breaks through the vertebrae. When the vertebrae are cut 
through, some shreds of soft parts may remain. These may be divided 
by scissors, or be left to be torn in the second stage of the operation — 
the extraction of the trunk." 

The delivery of the trunk and limbs of the child is now to be effected, 
mainly by pulling upon the arm ; but, should the force requisite be con- 
siderable, it will be proper to pass the blunt hook into the axilla of the 
opposite side, in order to economize the tractile force on the depending 
arm. Care must, however, be taken not to use the hook with too great 
force, as by causing the premature descent of the upper shoulder we 
would throw the great diameter of the shoulders across the pelvis, and 
thus, it may be, render the extraction of the trunk a matter of increased 
difficulty. Generally speaking, no great difficulty, in the absence of 
pelvic deformity, will be encountered in this stage of the operation ; and 
steady traction will cause the shoulders, trunk, and breech, successively 
to pass along the pelvic canal. The head, if completely separated, will 
move to the side, and will be no obstacle to the passage of the body. 

The extraction of the head of the child, which constitutes the third 
stage of the procedure, is by no means an easy operation, and is some- 
times, in fact, the most difficult point of all. A good deal will depend 
upon the condition of the uterus as regards contraction. During the 
second stage, it will be the duty of an assistant to keep up steady pres- 
sure upon the fundus of the uterus, and to follow it downwards as the 
trunk is being gradually expelled, so as to encourage, as far as may be 
possible, efficient and symmetrical uterine contraction, under the influ- 
ence of which the head will be grasped, forced down in the direction of 
the cavity, and maintained in a comparatively fixed position. Another 



REMOVAL OF THE HEAD. 493 

conflition likely to exercise an important influence is the state of the 
head itself, which, if decomposition has advanced, will be easily com- 
pressible, the flat bones being so loosely connected with each other as to 
admit of overlapping to a very unusual extent. Various methods have 
been suggested and practised for the extraction of the head from the 
uterus. The instances in which it is expelled by the natural efibrts are 
few, and no confidence can, for obvious reasons, be placed in the occur- 
rence of such a result. In some cases, it has been successfully removed, 
when compressible from putrefaction, by the fingers of the operator ; but, 
in almost all ordinary cases, instrumental aid is required, when we have 
the forceps, the blunt hook, the crotchet, and the cephalotribe to select 
from. 

The great obstacle, in such cases, arises from the mobility of the head, 
which rolls about within the cavity, and can sometimes only be seized 
w^ith difficulty. If, however, the head can be steadied and pressed down- 
wards by the assistant, whose hands are employed for this purpose in the 
hypo,2:astric region, the difficulty in question may be overcome. If it be 
possible to fix the crotchet, or a small blunt hook, in the foramen mag- 
num or orbit, success may, in this way, with the aid of the fingers, be 
quite practicable ; but the risk of the crotchet slipping is so considerable, 
that the more experienced modern operators have pretty much discarded 
that instrument in favor of the others which have been mentioned. The 
safest and most satisfactory operation, when it is practicable, is that by 
the ordmary midwifery forceps. The difficulty in this, as in the other 
operation, is to fix the head ; for, as soon as one blade is introduced, the 
head may escape to the upper part of a relaxed uterus, or to either side, 
so as completely to elude the grasp of the blades ; but if we can succeed 
in seizing the head, either antero-posteriorly or laterally, delivery will 
usually be completed without any further obstruction. The only other 
point to which it is necessary to pay particular attention, is the adjust- 
ment of the blades in such a manner as may obviate the possible danger 
arising from jagged spicula, which may project from the several vertebrae, 
or from such splintering elsewhere as may possibly have been the result 
of previous operative efibrts. 

There are cases, however, in which much more serious difficulties 
attend the extraction of the retained head. The worst examples of this 
are instances in which there is pelvic deformity, and in which it may be 
quite impossible for the ordinary diameters of the head to pass. In 
these, and in the more difficult of the cases unconnected with pelvic dis- 
tor;ion, it has been suggested that the perforator should be used. It is 
to be feared, however, that even in the hands of the most skilful, great 
risk will attend the use of that instrument ; and, even if it were not 
so, it must be admitted that the operation is one which we would not, 
without great apprehension, intrust to the inexperienced. Hazardous as 
the perforator always is, it is in this instance peculiarly so, owing to the 
mobility of the head, in consequence of which it may rotate suddenly 
and unexpectedly at the moment of perforation, and thus direct the sharp 
point of the instrument against the uterine w^all with possible results too 
fearful to contemplate. If we are able, by means of external manipula- 
tion, to fix the head against the brim, the perforator may be successfully 



494 DECAPITATION. 

employed against the occiput ; but, as mere pushing force would most 
likely dislodge the head, it is proper to combine boring with the more 
violent effort, which will, certainly, in economizing the latter, conduce to 
the safety of the operation generally. After perforation, and evacuation 
of the contents of the cranium by a process exactly similar to that which 
will be described under the head of Craniotomy, the extraction of the 
head by the guarded crotchet, or still better, by the craniotomy forceps, 
will be a matter of no great difficulty ; but, in both cases, the greatest 
possible care should be taken, as the head descends, to preserve the soft 
parts from laceration by the splintered fragments of the bones. The 
Cephalotribe is an instrument for which, in the management of such 
cases, we must express a very decided preference, as being both safer 
and surer than either the perforator or the crotchet, and almost as simple 
as the forceps in its application and management, as will be hereafter ex- 
plained. And, after discharging its special office of crushing the head, 
which is of such importance in contraction of the brim, the cephalotribe 
may further be employed as an extractor. 

It is not only as a sequel to the operation of decapitation that extrac- 
tion of the head has to be effected ; but it is also sometimes required 
under other circumstances, such as its accidental separation after the 
operation of turning. This is not likely to occur in experienced hands, 
but the separation of the neck of a putrid child does not require much 
force, and might happen to any one. Far less excusable are the cases in 
which in a breech presentation, or after turning, the head is arrested at 
the brim, and such violence is used in attempts at extraction as to result 
in tearing the trunk away from the head. In the absence of evidence of 
the death of the child, it is scarcely to be conceived that any one would 
use such violence as would of itself sacrifice the life of the child. But, 
if the child be dead, the operator might imagine that this is the safest 
and most natural method of delivery, and act accordingly by employing 
an amount of force which, in the interests of the mother, is quite unjusti- 
fiable, even should he succeed in his endeavor, seeing that he has, in the 
forceps and the perforator, agents by which maternal risk is materially 
reduced. 



VARIOUS METHODS OF TURNING. 495 



CHAPTEE XXXI. 

TURKIXG. 

Various Methods of Turning: Turning as practised by the Ancients. — Podalic 
Version. — Circumstances ivhich call for., and Conditions favorable to the Ope- 
ration. — The Operation in Detail: Choice of Hands; Introduction of the 
Hand: Passage of the Os: Seizure of a Foot or Knee. — Circumstances ichich 
render Turning Difficult : Difficulty in Seizing the Foot. — Child to be Turned 
Forwards. — Management of the Case after Version. — Pelvic Version. — Cepha- 
lic Version. — Turning in Contracted Pelvis : Degree of Distortion which may 
admit of Turning. — Turning contrasted with the Long Forceps, and as a Sub- 
stitute for Craniotomy. — Special Difficulties. — Bi-manual or Bi-polar Version: 
Processes of Wigand, Lee, mid Braxton Hicks. 

The operation of Turning, in its most extended sense, implies a ma- 
noeuvre by which one of the poles of the long diameter of the child, 
■which has not originally been the presenting part, is brought into the 
brim of the pelvis, the long diameter of the foetal oval being thus made 
to correspond to the long diameter of the uterus. Two varieties of turn- 
ing may therefore be practised : these are turning by the head, or, as it 
is generally termed. Cephalic Version ; and turning by the feet, or Po- 
dalic Version. A special modification of the latter, in which the breech, 
and not the feet, is brought down, has been occasionally practised, and 
separately described. 

From the time of Hippocrates down to the middle of the sixteenth 
century, Cephalic Version was almost exclusively practised, the head of 
the child being assumed to be the only natural presentation. This as- 
sumption led to the frightful practice of turning by the head in all pre- 
sentations of the pelvic extremity. It is quite clear that both Aristotle 
and Celsus held more correct views ; but the practice of Hippocrates, 
nevertheless, held its ground until the period which we have mentioned ; 
so that, up to that time, the ordinary operation of podalic version, as 
practised in the present day, was quite unknown. In 1561, Pierre 
Franco, in a work devoted chiefly to Surgery, suggested the mode of 
turning by the feet, and this was subsequently adopted by Par^, Guille- 
meau, Mauriceau, Baudelocque, and Lachapelle, to the complete exclu- 
sion of the cephalic operation. The difficulties which, under certain 
circumstances, surround the modern operation, seem, as late as the end 
of last century, to have suggested doubts as to its propriety in the 
minds of Flamand, Osiander, and other distinguished accoucheurs of that 
time, who therefore suggested that the practice of Hippocrates should be 
resorted to in all but original presentations of the breech or feet, to the 
exclusion, absolutely, of the new method. These views found favor 



496 TURNING. 

chiefly in Germany, but the podalic method made steady progress, and 
came ultimately to be generally adopted. The contemptuous manner, 
however, in which cephalic version was passed over or condemned by 
many of the most eminent writers of this later period, led for a time 
to the complete abandonment of this process, in favor of podalic version: 
but, in the present day, its value finds general recognition in a certain 
class of cases, — limited, no doubt, in point of numbers, as will be more 
particularly shown in the sequel. 

What is now, however, universally described as, par excellence^ the ope- 
ration of Turning, is Podalic Version, which consists in bringing down 
one or both feet when another part presents, and thus converting it into a 
footling presentation. The circumstances which call for this operation 
embrace a large proportion of all cases in which a speedy delivery is re- 
quired, and especially those in which the necessity has arisen early in 
the course of labor. Among the circumstances thus alluded to, may be 
mentioned placenta prsevia, prolapse of the cord, sudden death of the 
mother, certain cases of rupture of the uterus, and, in the opinion of 
many, cases of moderate pelvic distortion, in which it has been proposed 
as a substitute for the forceps, or the more formidable operation of crani- 
otomy. In transverse or shoulder presentations, again, it is the invari- 
able procedure ; and, in so far as this particular case is concerned, it has 
already been described at some length. 

It is of the first importance that the conditions favorable to the operation 
should be correctly appreciated. As it is usually performed, it is essen- 
tial that the os and cervix should be sufficiently dilated to permit of the 
passage of the hand ; but, as a moderate degree of dilatation only is requi- 
site for this, it follows that turning is available at a stage of labor con- 
siderably earlier than we have seen to be necessary for the safe employ- 
ment of the forceps. Another favorable condition applicable alike to all 
cases, is, that the membranes should be intact. The reason of this is ob- 
vious ; for, so long as the liquor amnii remains, the walls of the uterus 
are separated, in proportion to its quantity, from the body of the child, 
the mobility of which is consequently greater. Nothing, indeed, con- 
tributes so much to the ease with which turning is effected as this ; and, 
if the waters have escaped, and the womb has thus been permitted to 
grasp the body of the child, the operation is then found to stand in a 
very different category. The condition of the os as regards dilatahility 
is another most important consideration, for a rigid or unyielding condi- 
tion of this part of the passage is justly looked upon as an unfavorable 
circumstance, and it is therefore proper to wait, so long as the membranes 
remain unruptured, until nature overcomes this resistance. 

The Operation, — The condition of the bladder and rectum having been 
attended to, the woman is, in the first instance, to be placed in a conve- 
nient position. Some operators prefer that she should be on her back, 
and others that she should be on her elbows and knees ; but the English 
operator will generally choose the ordinary midwifery position on the left 
side, the nates being brought to the edge of the bed, so as to be within 
convenient reach. She should then be brought under the influence of 
chloroform, or some other anaesthetic. This has the effect of facilitating, 
both directly and indirectly, the passage of the hand, by overcoming 



THE OPERATION. 497 

rigidity and spasmodic contraction, and obviating the embarrassment 
which may arise from movements which are the result of apprehension or 
pain. The uterus is to be supported by an assistant, or by the other 
hand of the operator. By this means valuable assistance is afforded, by 
movements which are made in concert so as to bring the lower extremi- 
ties of the child within reach. 

The directions which are often given as to the hand which should be 
employed are of little practical value. Indeed, it is impossible in some 
cases, as in placenta previa, to recognize, before it has been passed into the 
uterus, the conditions which are held to indicate the use of the right hand 
or the left. Most people can act much more efficiently with the right than 
with the left hand, and there is no possible direction within the pelvis in 
which the right may not be passed. The positions in which there is most 
difficulty are those in which it may be necessary to direct the hand, with 
the palm forwards, towards the left sacro-iliac synchondrosis while the 
woman lies in the ordinary position on her left side. In this casa the 
hand must be pronated to the fullest extent ; and, if this movement of 
pronation is increased, as it may be by the operator turning his back to- 
wards the patient, it will pass without difficulty. The left hand would 
undoubtedly serve the same purpose here, if we could be sure of equally 
efficient action with it after the introduction. If the operator is left- 
handed, he should use the left hand in preference to the right ; and as 
our first object is to attain the abdominal surface of the child, — which, 
in the great majority of all positions, lies towards the back of the mother, 
— and as it must clearly be easier to pass the left hand along the sacrum 
than the right, the left-handed operator has a certain advantage. For 
the same reason, he who is ambidextrous should use that hand which may 
best suit the position of the child ; but, if the position be doubtful, he 
should invariably select the left, as being more likely to conduct him to 
the anterior surface of the child's body, while at the same time the flexion 
of the fingers will correspond to the axis of the pelvis. 

The operator should take off his coat, and bare his arm, so as to 
obviate, as far as is practicable, any inconvenience which may arise from 
pressure upon the muscles. The hand and arm are then to be liberally 
smeared with lard, and the points of the fingers, which are brought to- 
gether like a cone, are introduced within the vulva, and steadily pushed 
upwards in the axis of the outlet. In the event of unusual contraction 
at this stage, the obstacle will, to some extent, be overcome by separat- 
ing the fingers, so as to stretch the parts. No such difficulty, however, 
usually exists, but a more important one is encountered as the knuckles 
approach the orifice of the vagina. This is increased by the action of 
the constrictor vaginae muscle, especially in cases in which anaesthetics 
are not employed; but the resistance, by the stretching action of the 
fingers, combined with moderate and unremitting pressure, will speedily 
be overcome, when the rest of the hand will pass into the vagina, the 
muscles retracting upon it as it advances, and ultimately grasping the 
wrist. It is at this stage proper to pause, which affords us an oppor- 
tunity of more carefully examining the presenting part, and, it may be, 
of ascertaining the direction in which the hand is to be passed, with 
greater certainty than can be attained by the finger only. 
32 



498 TURNING. 

The operator, bearing in mind the curve of the pelvic axis, now alters 
the direction of his hand, so that its advance may coincide more with the 
axis of the brim. His subsequent procedure will depend chiefly upon 
the condition of the os. If it is well dilated, soft, and distensible, the 
hand may be passed at once, and turning will probably be effected with 
such ease as may astonish the inexperienced. But, if the os be com- 
paratively undilated, or in any degree rigid, he must proceed more warily, 
so as to avoid the slightest approach to violence — introducing first one, 
then two, and subsequently the remaining fingers, in the most cautious 
manner possible. It is generally said that, to warrant an attempt at 
turning, the os must be dilated to the extent of a crown-piece. This is, 
of course, only intended as an approximation ; and as much or more will 
depend on the dilatability, as upon the stage of actual dilatation. 

If the membranes are still unruptured, another object in avoiding 
abruptness in manipulation is to preserve the membranes intact. With 
this in view, therefore, we direct the fingers, so soon as they have passed 
within the os, between the uterine wall and the external envelope of the 
ovum ; and, the connection between those parts being lax, no great diffi- 
culty is generally encountered in passing the hand upwards, without rup- 
turing the membranes, in the direction of the feet. 

No part of this process is, however, to be attempted, without reference 
to the natural expulsive efforts. If the uterus is acting in the usual 
manner by rhythmical contraction, we should choose the period of re- 
laxation for the advance of the hand ; but, so soon as the advent of a 
pain is announced by contraction of the uterine walls, the hand should be 
allowed to lie quite flat and inactive, with the palm towards the child, 
until the period of relaxation marks the moment when our efforts may be 
safely resumed. Any attempt at continuous effort is wrong in principle, 
and is, we may be sure, apt to cause laceration, and even rupture of the 
uterus. This rule is one which is not observed in practice so strictly as 
it ought to be, and the wonder is, that accidents are not more frequent 
than they actually are, in cases where force is employed by the operator 
with no reference whatever to anything save the resistance which he en- 
counters. It will, however, as must be confessed, often be found that 
the stereotyped direction to act during an interval, and pause during a 
pain, cannot well be adopted, for the simple reason that the contact of 
the hand excites the uterus to continuous, or at best remittent action, so 
that if we are to wait for absolute inaction on the part of the uterus, we 
may abandon the effort altogether. Such continuous or spasmodic action 
as this, may be, as we have seen, allayed by anaesthetics ; and, if it 
should persist, we may still succeed, although it is necessary, in such in- 
stances, to act with redoubled caution and deliberation. 

As soon as the hand has reached so high in the uterus that the in- 
ferior extremity of the child can either be felt, or may be assumed to be 
on the same level, the sac of the liquor amnii may be ruptured, and the 
fingers passed in the direction of the foot or knee. A too strict observance 
of this rule is, however, undesirable ; for example, when the foot or knee 
is lower in the uterus than usual, we might then advance the hand further 
than is necessary, and, of course, if Ave come upon the edge of the pla- 
centa, the membranes must be pierced at once. The rupture of the mem- 



PODALTC VERSION. 



499 



branes is easily effected, by an effort of the fingers or the action of the 
nails in the direction of the foetus ; but with this the mechanical advan- 
tage of the liquor aranii is not lost, as it is still retained by the efficient 
plug formed by the arm which occupies the os uteri. This renders the 
actual version an easy matter. The fingers of the operator lay hold of a 
foot or a knee, w^hich in withdrawing his hand, he brings with him, choos- 
ing, if he can, a moment of uterine rest for the purpose, and availing 
himself, if it be necessary, of the assistance of the other hand, which is 
to be applied externally. As this is being done, the original presenta- 
tion retreats from the lower seo;ment of the uterus, so that the turnino; 
part of the operation is complete. 

Much argument has been wasted as to the propriety of bringing down 
one leg or two. The sound rule in practice is, that when we succeed in 
securing one foot, we should never 

pause to search for the other ; as Fig. 180. 

one is all that is necessary, un- 
less, perhaps, in cases of pelvic 
deformity, which we shall after- 
wards more particularly allude to. 
Kay, more than this, the descent 
of one leg has a positive advan- 
tage as compared with two, as 
thus, by increasing the diameter 
of the pelvis of the child, the 
parts are more thoroughly dila- 
ted, so as to admit of the ulti- 
mate passage, rapidly, and with 
comparative safety, of the head 
of the child. And, as this is the 
stage at which the life of the child 
is most frequently compromised, 
it is assumed, that bv abridoi;in<2; 
Its duration, foetal life in the 
aggregate must, by this process, 
be saved. Still, when a very 
rapid delivery is desired, the ope- 
rator knows that he has a better 
and more efficient hold upon two limbs than he can have upoa one ; and 
he will, therefore, very naturally, bring down both when they are within 
easy reach ; but, when the discovery and seizure of the other limb in- 
volves extra effort or delay, not even in such a case as this should he be 
otherwise than content with what he has already achieved. The foot or 
knee which is lowest in the womb or easiest of access should at once be 
seized ; but, in a transverse presentation, there is no doabt that turning 
will be more easily effected when we seize the leg of the side opposite to 
the presenting shoulder. 

Constriction of the vaginal orifice, and incomplete dilatation of the os, 
are, as we have seen, difficulties which are often encountered in attempts 
at turning. Far more serious than those are the obstacles which we meet 
with, when the conditions which we have indicated as favorable to the 




Podalic Version. 



500 TURNING. 

operation do not exist. A case, for example, may be brought under our 
notice for the first time at an advanced period of labor, in which the os 
has been permitted to dilate, the membranes to rupture, and the present- 
ing part to descend in the pelvis before the nature of the case has at- 
tracted particular attention, or the necessity for turning has been recog- 
nized. The most familiar illustrations of this are shoulder presentations, 
already described. In such cases, the liquor amnii has, we shall suppose, 
long since escaped ; the uterine walls have grasped the child in a firm 
embrace ; and the long-continued uterine action has forced the shoulder 
down into the cavity of the pelvis. If pelvic distortion should exist, im- 
paction may have taken place ; but, independent of this, mere tonic 
uterine contraction may so wedge the head as to render the case practi- 
cally as bad as one of real impaction. In such cases, the difficulties are 
often insurmountable, for the operator cannot even pass his hand beyond 
the presenting part, and is obliged to desist, or have recourse to some of 
the other operations of midwifery. It is perfectly impossible to describe 
what experience alone can teach — the amount of force which, in this, or 
any other stage of the operation, Ave are warranted in employing. Any- 
thing even approaching to what we would call violence, is not only im- 
proper, but ineffectual, so that moderate and sustained effort, comlained 
with an insinuating movement of the fingers, should always be preferred, 
as being comparatively both efficient and safe. If, for example, we were 
rudely and recklessly to thrust the hand into the vagina without observing 
the precautions we have detailed, we should, in all probability, inflict 
severe laceration on the parts ; but if, on the contrary, we act with cau- 
tion and discretion in a case precisely similar, we effect our purpose with 
ease and safety. The same principle obtains, and should never be lost 
sight of, in all the subsequent stages. 

Impaction implies resistance from the pelvic walls ; but we have obsta- 
cles of a not less insurmountable kind in the rigid condition of the os or 
uterine walls, when, although success by violence may be possible, it is 
only to be effected by what involves serious risk to the mother. It is such 
considerations, therefore, based on general principles, which should be 
our guide in practice, and deter or encourage us in an individual case. 
It not unfrequently happens, as practice has taught every experienced 
accoucheur, that these successive stages of difficulty have been, one by 
one, surmounted, and yet, at the very moment when success seemed just 
within our grasp, further progress was arrested. The tips of the fingers 
may even touch the knee or foot, and yet the inch or so of further ad- 
vance w^hich is required can scarcely, by any moderate effort, be achieved. 
This is a moment at which, in our eagerness, we are very apt to pass the 
line which separates prudence from rashness. By a vigorous thrust of 
the arm, we may be confident that we shall attain what we so much de- 
sire ; and it is with difficulty only that we can refrain from what alone 
seems wanting to complete success. We must, however, with firmness 
and what we may term self-denial, resist this inclination, and wait a little 
until, perchance, we may wear out the uterine resistance which consti- 
tutes the barrier to our progress. 

It is here, however, most unfortunately, that the straining of the fin- 
gers is apt, along with violent uterine contractions, to cause cramp of the 



PODALIC VERSION. 



501 



muscles of the hand, a condition which may absolutely paralyze our 
efforts. By resting for a time, or stretching the fingers, the power of 
the hand may return ; but it too often occurs that we find ourselves quite 
powerless just at the moment when we have come to count upon success 
crowning our efibrts. Xothing will remain for us, in such a case, but 
the withdrawal of the hand, to our great chagrin, and either the introduc- 
tion of the other, or the re-introduction of the same one after it has had 
time to recover. What is particularly annoying, when this is found to 
be necessary, is that the withdrawal of the hand from the uterus permits 
of the escape of what liquor amnii remains, and, consequently, of a still 
greater degree of uterine contraction upon the body of the child. Even 
in such a case, however, we may ultimately succeed by perseverance ; 
and, when the hand has again been introduced, our external manipula- 
tions may result in bringing the feet within reach. But, with this 
measure of success, our difficulties may be far from being at an end. 

It sometimes happens that the hand is introduced, the foot seized and 
brought down to the os, and yet complete version cannot be effected. 
When the presence of the liquor amnii, or a relaxed condition of the 
uterine walls, permits of a certain degree of freedom of motion, the pre- 

Fig. 181. 




Turning by the Noose or FiUet. 



senting part will recede as the foot is pulled downwards to the os. Bat, 
when the body of the child is firmly grasped by the uterus, this is not 
the case, and some further manoeuvring, external or internal, will be re- 
quired to complete the operation. The mode of acting externally through 
the abdominal walls has already been alluded to, and will again be more 
particularly described. The internal manipulation in these cases consists 
in pushing up the presenting part while we pull dow^n the foot. In other 
words, we act upon the two poles of the long diameter of the foetus in- 



502 TURNING. 

stead of one only. The vagina, however, being already fully occupied 
by the hand of the operator, it will be impossible for him to act upon the 
presenting part without letting go the hold which he has of the foot ; but 
this is of all things what he least wishes to do, as there is often great diffi- 
culty in securing it again. By a very simple expedient he is able to effect 
all that he desires. A running noose of tape or cord is to be passed over 
the forearm, and is then pushed upwards over the hand and beyond the os 
calcis and instep of the foot. When tightly drawn, this secures an admirable 
hold, and the hand may be withdrawn, or at once brought to bear upon 
the head or pre3enting part, while the other hand pulls steadily upon the 
noose. The same principle has been adopted, by Braun and other 
eminent Continental practitioners, when difficulty arises in seizing the 
foot, and various instruments have been devised by them with this pur- 
pose. One of these is described by Hyernaux of Brussels, under the 
name of po7^te-lacs. When such combined action upon the two extremi- 
ties of the child fails, it may be impossible to effect delivery in this way ; 
so that we may have to fall back upon the perforator or decollator, as 
the case may be. Before finally abandoning the attempt to deliver by 
this method, we must be sure that we have pulled down the foot .in the 
proper direction, so as to turn the child forwards. An error here is not 
likely, as we would naturally pull the foot, when seized, directly towards 
the os; and if we have passed the hand along the abdominal surface, we 
can scarcely go wrong ; but it is quite possible that, by omitting this 
precaution, and passing the hand over the dorsal surface, we may not 
only find it vastly more difficult — if, indeed, it be possible — to reach the 
foot, but we may discover, in addition, that when it is reached and seized, 
turning is impracticable after all. 

It is generally recommended by systematic writers, that we should 
so manage the operation as to make sure that the abdomen of the child 
is turned, after version, towards the spine of the mother, as is indicated 
by the toes being directed towards the sacrum. This is, however, by no 
means a matter of such importance as it might appear, for if, as often 
happens, the toes should be pointed to the symphysis pubis, the trunk of 
the child will rotate as it descends, so as to bring the face ultimately into 
the hollow of the sacrum, whatever the original position may have been. 
But, when the natural rotation has not taken place, it has been found 
necessary to assist the movement by manual interference. The greatest 
caution must, in every case, be exercised to prevent, as much as may be 
possible, pressure upon the cord ; but, in so far as this is concerned, what 
has already been said in regard to presentations which are originally of 
the pelvic extremity, will serve for our guidance in those cases in which 
the pelvic end of the foetal oval is artificially, and for a particular pur- 
pose, brought down. One advantage of effecting version, so as to bring 
the dorsal surface to the front, will be to bring the cord naturally into 
the posterior part of the pelvis from the first, by which we are enabled 
to place it in that situation in which it is least likely to be subjected to 
severe pressure. 

When version is complete, we have converted the case, whatever it 
may originally have been, into a presentation of the feet. It remains, 
however, for consideration, whether we are to leave the case to nature, 



TURNING IN PELVIC CONTRACTION. 503 

or proceed to immediate delivery. It is almost always proper to pause, 
at least for a time, until we see what nature is likely to do; but, if the 
symptoms are such as to call for prompt action, wdiether in the interests 
of the mother or the child, w^e must act boldly, and without hesitation, in 
effecting immediate delivery. It should be remembered, that so long as 
the head of the child remains above the brim, the cord is not likely to be 
subjected to any dangerous pressure, so that, while nothing is lost by 
delay at this stage, something may be gained by pausing until uterine 
energy is awakened. If the cord has prolapsed, or has otherwise come 
within reach, at this or a subsequent stage, we will be guided by the 
presence or absence of pulsation, and the other evidences of vitality of 
the foetus, in determining whether to precipitate matters or not. During 
the descent of the trunk, we must observe the usual precautions, but at 
the last stage there must be no delay, and the forceps and restoratives 
should be at hand, so that we may at once have recourse to them should 
occasion arise, and that in the manner described in the chapter on Pelvic 
Presentations. 

The term Pelvic Version, as employed by English writers, implies an 
operation in w^hich the breech, and not the feet, is brought to the os 
when another part originally presents. That this may, in rare instances, 
be effected by dexterous management, does not admit of dispute ; but, at 
the same time, such a course of procedure is so obviously one of greater 
difficulty, as compared with podalic version, that we need not wonder 
that the former operation, which, indeed, never attracted much notice, 
has been all but entirely superseded by the latter. As regards the 
ancient operation of Cephalic Version, it seems certain that tliere are 
cases of transverse presentation in which we would be justified in making 
an attempt at what is a less severe operation to the mother, by pushing 
up the shoulder, and so manipulating as to cause it to be replaced at the 
OS by the head. Success could here only be hoped for when the child is 
still movable within the uterus, and the methods most likely to be 
attended with success are either the " bi-manual" or "bi-polar" method, 
or Dr. Maxson's postural method, both of which will be afterwards de- 
scribed. 

The application of the operation of ordinary or podalic version to cases 
of pelvic contraction, is a mode of procedure wdiich was practised long 
before the forceps was discovered. Nor did the discovery of that impor- 
tant instrument throw the earlier operation entirely into the shade ; and, 
indeed, we find Denman, and other contemporary writers, giving minute 
directions, a hundred years ago, as to the manner in which the operation 
is, under such circumstances, to be effected. There can be no doubt, 
however, that as operators became more skilled in the use of the forceps, 
and the scope of that instrument became more thoroughly understood, 
the number of cases of contracted pelvis in wiiich turning was practised, 
was more and more diminished in number, until, at last, the operation 
fell into complete disuse. The operation was, however, revived and 
strenuously advocated by Simpson ; and, although some experienced 
operators have condemned it, it is the fact that many of the most distin- 
guished living accouch-eurs have adopted his views and practice. Simp- 
son maintained his position by arguments and facts, — the former being 



50-1 TURNING. 

characterized by the ingenuity and ability which he possessed in such a 
high degree, and of which his works afford no more striking illustration. 

The fact that this operation involves a question of conservative mid- 
wifery, is one which may alone suffice to secure for the subject earnest 
and careful attention ; and this, indeed, it has received from almost all 
recent writers. In cases in which the head is arrested by pelvic contrac- 
tion at the brim, we have three possible modes of action between which 
we must decide — turning, forceps, or craniotomy. The first two are 
conservative, the last destructive. The dangers and difficulties of the 
long forceps are well known, and have been fully described ; but there 
are, probably, few operators who would not rather risk them than wan- 
tonly destroy a living child, as we have too good reason to believe has 
often been done. The case is quite different when the child is dead ; for 
here w^e determine upon a plan of action which we undertake solely in 
the interests of the mother, when craniotomy stands before us under quite 
another aspect. The first point of importance, then, is to determine 
whether or not the child is alive ; and if, this being established, we fail 
to deliver by the long forceps, or that instrument is contra-indicated, the 
question before us simply is : — Shall we turn, or perforate — ^attempt to 
save the child, or at once destroy it ? 

The reply to this question, involving as it does such weighty responsi- 
bility, will depend upon a variety of circumstances, of which the most 
important, perhaps, is the degree of pelvic distortion which actually 
exists. It is impossible to fix the exact measurement of the conjugate 
diameter which maybe held to warrant an attempt at turning ; and, even 
were it possible to determine this with fractional accuracy, our modes of 
practising pelvimetry are so uncertain, that it is a matter of the greatest 
difficulty, even to the most dexterous, to gauge a pelvis during labor. 
Dr. Churchill fixes the limit at two inches and six-eighths, and Dr. 
Barnes — as we believe, with more justice — at from three and a quarter 
to three and three-quarter inches ; so that we may say, in round num- 
bers, that when the conjugate diameter is less than three inches^ to 
attempt to turn would be to subject the woman to needless risk, as we 
may be confident that nothing but failure could attend our efforts. 

But, seeing that this is a question where an eighth of an inch may 
make all the difference between success and failure, and it is impossible 
to ascertain the exact space with anything more than what is at best an 
approach to accuracy, it follows, as a possible contingency, that we may 
actually turn, and subsequently find that we have miscalculated either 
the conjugate diameter or the size of the head, and that the latter will 
not pass. Such a failure as this is not so serious a matter as might at 
first sight appear ; for if we have thus to resort ultimately to craniotomy, 
that operation will be attended with very little more difficulty and no 
greater risk than if we had begun by perforating the vertex. The 
mother, no doubt, has been subjected to the risks of turning in addition 
to those of craniotomy, but we are surely warranted in incurring this 
additional risk in the hope, if successful, of saving the child. 

It is unnecessary again to refer at any length to the positive advan- 
tages which are claimed by Simpson for the operation of turning in con- 



TURNING IN PELVIC CONTRACTION. 505 

tracted pelvis, as these have already been fully described.^ The bi- 
parietal measurement of the head is, as he points out, greater than the 
bi-mastoid ; and as, in turning, the latter enters the contracted space 
first, he argues that, on obvious mechanical principles, the compressihility 
of the head is increased by version ; and, as it is well known that in some 
cases of this kind, when the child has been born alive, the parietal bones 
have been found to be flattened or indented by the pressure, he concludes 
that turning under such circumstances is not only a reasonable proposal, 
but an actual gain in facility of delivery and safety to the child. Simp- 
son's theory has been contested by M'Clintock, E. Martin, and others, 
upon the whole, we think, unsuccessfully ; while, in corroboration of his 
views, a considerable w^eight of practical evidence has accumulated, of 
which the folio winor from Barnes' lectures is a strikinor illustration : "In 
the first place, let me state a fact which I have often seen. A woman 
with a slight contracted pelvis, in labor with a normal child presenting 
by the head, is delivered, after a tedious delay, spontaneously or with 
the help of forceps ; the head has undergone an extreme amount of 
moulding, so as to be even seriously distorted. The same woman in labor, 
again, is delivered breech first ; the head exhibits the model globular 
shape, having slipped through the brim without appreciable obstruction. 
In the second place, I have, on several occasions, been called to an ob- 
structed labor in which the head was resting on a brim contracted in the 
conjugate diameter. Of course, nature had failed ; the vis a tergo was 
insuflicient. I have tried the long double-curved forceps, trying what a 
moderate compressive power, aided by considerable and sustained trac- 
tion, would do to bring the head through, and have failed. I have then 
turned, and the head coming base first, has been delivered easily. Upon 
this point I cannot be mistaken." 

The operation of turning in contracted pelvis may thus present itself 
to us under two distinct aspects — as a substitute for the long forceps, and 
as a substitute for craniotomy. As regards the former, the experience of 
many indej^endent observers would seem to show that, on the principle 
suggested by Simpson, turning may succeed when the forceps will fail ; 
that instrument being, therefore, applicable to those cases only in which 
the contraction is moderate in degree. Owing to the difficulty of ascer- 
taining the exact dimensions of the head and pelvis, a safe, and, we be- 
lieve, a very general practice, is first to make a cautious attempt with 
the long pelvic-curved forceps, and failing that — which, in skilful hands, 
is a safer operation to the mother — to proceed at once to turn. Turning 
as a substitute for craniotomy, is a more important point still — so im- 
portant, indeed, in a conservative sense, that it cannot fail to command 
the attention of every conscientious practitioner. Impaction of the head, 
or difficulty of displacing it, so as to admit of the passage of the hand, 
and a degree of pelvic contraction beyond the limit which we have stated, 
are the two principal contraindications of the operation of turning. The 
death of the child is not necessarily so, for craniotomy at the brim is by 
no means so safe an operation but that it may fairly be balanced against 
turning, even in the interests of the mother alone. 

See Figs. 151 and 152, p. 4-i5. 



506 



TURNING. 



The operator must be prepared, in turning in a contracted pelvis, to 
encounter special difficulties in individual cases, which it is impossible 
fully to describe, or even to anticipate. Following the example of all 
writers on the subject, we have alluded to the operation in reference 
only to simple conjugate contraction at the brim, b}^ far the most common 
of all the varieties of distortion. It requires no argument to show that 
rules applicable to this alone must often fail. In the typical malacostean 

FiR. 182. 




Malacostean Pelvis, 



pelvis, we may find an actual increase in the conjugate diameter, coupled 
with such deformity as may render craniotomy, or possibly the Csesarean 
operation, the only practicable methods of delivery. In those cases in 
which there is asymmetrical distortion, it is of importance that the large 
or occipital end of the head should, if possible, be thrown into the larger 
half of the pelvis. To effect this is, however, a matter of very consider- 
able difficulty ; and we apprehend that the rules laid down by E. Martin 
and others for effecting the object cannot be held as being of much prac- 
tical value. The accoucheur must in no case lose sight of the infinite 
varieties of distortion to which allusion has already been made, as these 
may at any time call for special adaptations, to which thorough operative 
capacity and an intimate knowledge of the subject can alone guide us. 
Another possible difficulty we have known to occur in connection with 
twin pregnancy, in which the operator, after introducing his hand, has 
seized the foot of the wrong child. 

The operation to which alone we have hitherto alluded, is the ordinary 
operation of turning, necessarily involving the introduction of the whole 
hand within the cavity of the womb. There is, however, another opera- 
tion, or rather a modification of this operation, which may be practised 
with less risk to the mother, and even, as it would seem, under circumstances 
which would render the ordinary procedure difficult, if not impossible. 
This is Bi-manual or Bi-polar Version, an operation which is attracting, 
year by year, more and more of the attention which it merits. Early in 
the present century, Wigand suggested a method whereby the presenta- 
tion of the child could be altered without the slightest, risk to the mother, 
by external manipulation alone. His observation applied to transverse 



BI-POLAR METHOD. 507 

presentations only, and his plan was, — having ascertained, by vaginal 
examination, the exact position of the foetus, — so to press upon the child 
externally as to bring to the os uteri that pole of its long diameter which 
was lowest in the pelvis. In a word, he claimed to be able to practise 
both cephalic and podalic version, without even introducing a finger into 
the vagina, although he seems to have employed the inner hand to guide 
or receive the head or breech into the os. The directions which he gives 
include elaborate, but, we fear, impracticable instructions as to the 
manner in which we should proceed — with the view of availing ourselves, 
to the utmost, of gravitation — to place the patient, now on one side, and 
again on the other, at various successive stages of the operation. It is 
quite certain that Wigand never contemplated anything more than partial 
version, so that his novel manoeuvre, which found considerable favor in 
Germany, was never supposed to be applicable to cases of placenta pr?e- 
via, nor to any other case in which the head was originally the present- 
ing part. 

Dr. Robert Lee seems to have been the first to su";2;est a method of 
turning, which is the opposite of that to which Wigand lent the weight of 
his authority. In cases of incomplete dilatation of the os uteri, he 
brought two fingers, which he passed into the uterus, to bear upon the 
head, which he first of all attempted to displace; and, when he had suc- 
ceeded in this, he successively pushed aside those parts which came 
opposite the os in the same direction as that in which the head had dis- 
appeared, until, ultimately, the feet were made to present, or were 
brought within reach of the finger, and so secured. It is to Dr. Braxton 
Hicks that we in this country owe the method of combined external and 
internal version, although, as has already been stated, the claim of 
priority has been made out in favor of Dr. M. B. Wright of Cincinnati. 
This procedure bids fair to supersede, in a great measure, the old 
method, and we can unhesitatingly, and from personal experience, vouch 
for its efficacy in practice. The conditions which have alread}^ been 
mentioned as favorable to ordinary podalic version, are even more essen- 
tial to the successful performance ot the bi-polar method. Unless, there- 
fore, the child is movable with tolerable freedom within the uterus, we 
can scarcely expect to succeed in effecting version by this, as we should 
probably fail by the other method. But, until we have thoroughly tried 
the effect of aniesthetics in reducing rigidity and tonic contraction of the 
uterine fibre, we should not too readily abandon the chance which this 
operation may possibly afford us, and we may be sure that if, at any 
stage, the conditions which are generally considered to be favorable to 
the ordinary operation are manifested, we may hope to succeed by this 
process. The bi-polar operation is, as will be inferred, a combination of 
the methods of Wigand and Lee, in the course of which, while the ope- 
rator brings one hand to bear upon the uterus through the abdominal 
walls, he simultaneously operates upon the other end of the child by 
means of the finger, which he has introduced into the vagina and through 
the OS uteri, causing the one pole to descend, as he encourages the other 
to recede. 

In so far as transverse presentations are concerned, we are indebted to 
Dr. Robert Lee for having first clearly pointed out that when the child 



508 



TURNING. 



is situated quite transversely within the womb, its knee is generally 
within a finger-length of the os uteri, and thus in some transverse presen- 
tations, it is not very difficult to hook down the knee. The child, how- 
ever, as both he and Wigand have shown, does not usually lie trans- 
versely, but rather obliquely in regard to the transverse axis of the 

uterus, which removes the knee 
to some extent from the imme- 
diate grasp of the finger, and 
brings at the same time the opera- 
tion of cephalic version somew^hat 
more within the range of possi- 
bility. But, while we thus re- 
cognize, as we can scarcely fail 
to do, the advantage of the bi- 
polar method over either of those 
in which one pole only is acted 
upon, the former admits, as will 
be seen, of a far more extended 
application, such as was never 
sought to be accomplished, so far 
as we can see, either by Wigand 
or Lee. In cases of placenta 
prsevia, therefore, or in cases of 
contraction of the brim of not less 
than three inches in the conju- 
gate diameter, the head being 
the presenting part, it is quite 
possible, and in some instances 
by no means difficult, to effect 
complete version by the bi-manual 
method, and thus avoid many of 
the risks of the ordinary opera- 
tion. For the details of this pro- 
cedure we shall here quote the 
directions of Dr. Braxton Hicks. 
" I will now proceed to describe the mode by which I effect podalic 
version. We will suppose a case where everything is natural ; the os 
uteri dilated to admit one or two fingers, membranes perfect, and the 
face towards the right side. The patient may be placed in the ordinary 
obstetric position. Having lubricated my left hand, I introduce it as far 
into the vagina as is necessary, in order to reach a finger's length within 
the cervix. Sometimes it requires the whole hand, sometimes three or 
four fingers will be sufficient in the vagina. Having clearly made out 
the head and its direction, whether to one side or other of the os uteri, I 
place ray right hand on the abdomen of the patient towards the fundus ; 
I- then endeavor to make out the breech, which is seldom a difficult mat- 
ter. The external hand then presses gently but firmly the breech to the 
right side ; as it recedes, so the hand follows it either by gentle palpa- 
tion, or by a kind of gliding movement over the integuments, while at the 
same time the other hand pushes up the head in the opposite direction. 




Bi-Manual Version; First Stage. 



BI-POLAR METHOD, 



509 



so as to raise it above the brim. It may be mentioned that, Avhen the 
head has descended a considerable distance into the pelvic cavity, or 
more than half way through the os uteri, it is scarcely possible to lift it 
above the brim, especially if the uterus be active. 

" When the breech has arrived at about the transverse diameter of the 
uterus, the head will have cleared the brim, and the shoulder will be 
opposite the os. That is pushed on in like manner as the head, and 
after a little further depression of the breech from the outside, the knee 
touches the finger, and can be hooked down by it. It very frequently 
happens, when the membranes are perfect, that, as soon as the shoulder 
is felt, the breech and foot come to the os in a moment, in consequence 
of the tendency of the uterus to bring the long axis of the child coincident 
with that of its own. Should it, therefore, be difficult to hook down the 
knee, depress the breech still more, and it will be almost always the case 
that the foot will be at hand. 

"It will, sometimes, render turning more easy if, as soon as the head 
is above the brim, we pass the outside hand beneath it, and push it up 
from the outside alternately with 
the depression of the breech. All 
this can generally be performed 
in much less time than I have 
taken to describe it, although in 
some it requires gentle, firm, and 
steady perseverance, with such a 
supply of patience as is always 
demanded in obstetric operations. 
If the OS will only admit one 
finger, and the foot cannot be 
brought through in consequence, 
it can yet be retained at the os 
by pressing it Avith that finger 
against the inner surface of the 
OS ; the most convenient part be- 
ing against the anterior part ; be- 
cause the pubes will assist in sup- 
porting the pressure, while, at 
the same time, in most persons, 
unless very stout, the hand press- 
ing externally above the pubes is 
capable of assisting materially in 
retaining the leg in that position, 
and securing the altered change, 
ready for us to take advantage of 
it, should the case so require, as soon as the os dilates sufficiently; and 
the mere retention of the leg here is of considerable value, for, in cases 
of turning, even when we cannot effect turning immediately after having 
seized one of the limbs, yet the holding on to that part, and thereby fixing 
it, ultimately produces such an improved relationship between the uterus 
and its contents that the after operations succeed more easily. Should 
the child face towards the left side, the only difference required in ope- 




Second Stag- 



510 



TURNING 



rating is, that the breech be pressed toward the left side, and the head 
to the right." 

Further on, in regard to Cephalic version. Dr. Hicks continues : " We 
will suppose, first of all, a case where the uterus is not active, the liquor 
amnii not escaped, or only recently so, where the foetal head has not 
passed the os. Introduce the left hand into the vagina as in podalic ver- 
sion ; place the right hand on the 
Fig. 185. outside of the abdomen in order 

to make out the position of the 
foetus, and the direction of the 
head and feet. Should the shoul- 
der, for instance, present, then 
push it with one or two fingers 
through the cervix in the direction 
of the feet. At the same time, 
pressure by the outer hand should 
be exerted on the cephalic end of 
the child. This will bring down 
the head close to the os ; then let 
the head be received upon the tips 
of the inside fingers. The head 
will play like a ball between the 
two hands ; it will be under their 
command, and can be placed in 
almost any part at will. Let the 
head, then, be placed over the os, 
taking care to rectify any tendency 
to face presentation. It is as well, 
if the breech will not rise to the 
fundus readily after the head is 
Third stage. fairly in the os, to withdraw the 

hand from the vagina, and with it 
press up the breech from the exterior. The hand which is retaining 
gently the head from the outside should continue there for some little 
time, till the pains have insured the retention of the child in its new 
position by the adaptation of the uterine walls to its form."^ 

We shall make no apology to the reader for the length of this extract, 
and the prominence which we have thus given to the operation of bi-polar 
version, as we look upon it as one of the most important improvements in 
modern obstetrics, which is attracting an amount of attention ever on the 
increase, and which is, if we mistake not, likely, ere long, to take the 
place of the more familiar procedure of ordinary podalic version. 

The postural method, to which reference has already been made, has 
been suggested by Dr. Edwin R. Maxson, of Syracuse, N. Y., as appli- 
cable to cases of transverse presentation '^ and, although we at once re 
cognize an objection to this procedure in the impossibility of safe anges 
thesia, it must at the same time 




be admitted that the suggestion is 



an 



1 On Combined External and Internal Version : 
etc. London, 1864. 

2 See "American Practitioner." March, 1877. 



by J. Braxton Hicks, M.D., F.R.S., 



EMBRYOTOMY. 511 

important one, and the cases which Dr. Maxson quotes in support of his 
theory are both significant and striking. He assumes that the proper 
treatment in all ordinary transverse cases is to " push back the shoulders 
or get the head," and this, he assures us, is in most cases readily efi"ected 
by placing the patient in the genu-pectoral position, when the shoulder 
can be readily displaced, and the head brought down by the same hand. 
This, we apprehend, is a method of treatment w4iich, either alone or in 
conjunction with the bi-polar manipulation, may possibly prove to be a 
valuable addition to the means at our disposal in efifecting the operation 
of turning in any of its varieties. 



CHAPTEE XXXII. 

EMBRYOTOMY. 

Conditions rchicli warrant the Operation. — Ckaxiotomy. — Consists of Various 
Stages. — Perforation : Varieties of Perforators: Method of and Precautions 
to he Observed in Perforating : Cranial Contents to he Broken Up and Dis- 
lodged : Traction to he now Emjjloi/ed — Use of the Crotchet: where to Fix it : 
Dangers of: The Guarded Crotchet. — The Craniotomy Forceps : Removal of 
the Vault of the Cranium: Protection of the Maternal Tissues. — Davis' Os- 
teotomist. — The Scalp to he Preserved. — Turning after Craniotomij. — Canting 
the Base, after Removal of the Flat Bones, and bringing the Face Downwards. 
— The Cephalotribe : French and English Models : Cep)halotripsy the Final 
Stage in the Operation of Craniotomy : Details of the Operation : May the 
Cephalotribe be used as a Tractor ? Subsequent Extraction of the Trunk. — 
Craniotomy in Breech Delivery, after the Passage of the Trunk. — Embky- 
ULCiA : Evisceration of the Feet us : applicable chiefly to Impacted Transverse 
Presentation. — Van HueveV s Forceps Saw. — Dr. Barnes' process of Cranial 
Section by the Ecraseur. 

Embryotomy is, in one sense, the most objectionable of all the opera- 
tions of Midwifery; for, of all other possible modes of procedure, this 
is the one which most certainly involves destruction of the child. On 
this account, the accoucheur shrinks, with natural repugnance, from an 
operation which necessarily implies mutilation of a dead, and must de- 
stroy a living, child. Such, however, is a view which we are apt to carry 
to an extreme, and overlook, in so doing, the more important interests of 
the mother ; while we forget that circumstances do arise, when in full knowl- 
edge of the fact that the foetus lives, it may be the duty of the accoucheur 
unhesitatingly to sacrifice the child, as this is the only means by which 
he may reasonably expect to save the mother. 

Our first and earnest desire, of course, is to save, if it be possible, the 
child as well as the mother ; but, if it should become obvious that all 



512 , EMBRYOTOMY. 

hope of a result so favorable must be abandoned, we may be sure that 
we are fully justified in giving up the child, if we recognize in this the 
only mode of preserving the more important life. Nothing, of course, 
will justify this, short of an absolute conviction that the vectis, the for- 
ceps, and turning, are of no avail ; for then, and then only, are we justi- 
fied in laying aside the implements of conservative midwifery, and taking 
into our hands agents which are destructive to the child. On the Conti- 
nent generally, and especially in Roman Catholic countries, where the 
religious element comes more prominently into play, foetal life is, it must 
be confessed, more jealously guarded than with us. But, while we fully 
recognize the humane impulses which may thus sway a purely scientific 
decision, it must be affirmed that, whenever it is certain that a living child 
cannot pass, nothing can be more irrational than to await death of the 
child, before Ave act upon the conviction that it cannot live, — and thus 
allow the period to pass at which we may confidently operate in the ex- 
pectation of preserving maternal at the sacrifice of foetal existence. 

However lightly, on the other hand, we may view these considerations, 
evidence of the death of the child will always be held as of paramount 
importance, in all cases in which the operation of Embryotomy may offer 
itself for our consideration. When this is clear, all scruples will vanish, 
as we have the mother alone to consider; and, therefore, when the other 
modes of procedure are impracticable, we will proceed without hesitation 
to the performance of an operation which treats the dead foetus as a mass 
of inert matter, to be removed at the least possible risk to the mother. 

The conditions, then, which may be held as warranting the operation 
of Embryotomy are those in which the Forceps aiid Turning are of no 
avail, and which, at the same time, preclude the passage of a living 
child. In so far as the contraction of the conjugate diameter at the 
brim is concerned, we have already seen that, in the case of a fully- 
developed child, we can scarcely expect a successful result from turning, 
when that diameter is much less than tliree inches ; and this, therefore, 
we may take as the limit within which the operation may be demanded. 
Tumors of any kind, — bony, malignant, or ovarian ; atresia of any por- 
tion of the ordinarily distensible canal ; impaction of the head, or ex- 
treme contraction of the uterus, are illustrations of other causes which, 
independently of ordinary pelvic distortion, may render delivery by em- 
bryotomy the only method from which we can anticipate a favorable 
result. Although the history of former labors is, in such cases, to be 
admitted as an important consideration, in determining our course of pro- 
cedure, the conclusions of many independent observers show very clearly 
that this must not be allowed to take too prominent a position, as it not 
unfrequently happens that women who have had an ordinary labor before, 
under circumstances Avhich are apparently similar, are, if not relieved, 
subjected in subsequent labors to the greatest peril. This may be due, 
according to Barnes, to progressive pelvic contraction, or, as D'Outrepont 
holds, to progressive increase in the size of the children. But, on the other 
hand, we may fall into the opposite error, if Dr. Matthews Duncan's 
deductions are correct — that after Avomen have attained the age of twenty- 
nine, the weight of their children falls, — by supposing, that because 
craniotomy was found necessary on a former occasion, it must necessarily 



PERFORATION. 513 

be required in subsequent pregnancies which have been allo^yed to go to 
the full time. Among the rarer conditions demanding craniotomy, are 
impacted mento-posterior positions of the face, cases of locked twins, in 
which one head can only be released by perforating and reducing the 
bulk of the other, double-headed monsters, and hydrocephalus. 

There are, however, in addition to these, certain conditions of the 
mother which may call for the operation. It has already been shown 
that, in cases in which, from any cause, speedy delivery is required, 
turning is to be preferred to the forceps, when the dilatation of the os is 
not sufficient to admit of the safe use of that instrument: and to this it 
may now be added, that an even less degree of dilatation of the os will 
suffice for craniotomy than for turning, as all that is essential is space 
for the introduction of two fingers and the extremity of the perforator. 
In certain cases of convulsions, when there is great exhaustion, and in 
some instances of rupture of the uterus as already particularized, in 
which the state of the os forbids both the forceps and turning, it may be 
necessary for us to perforate. As a rule, however, and excepting the 
cases of rupture of the uterus alluded to, we should never operate by 
craniotomy while there is a possibility of nature prevailing, until we have 
given her a fair chance, and have waited to see what may be effected by 
the ordinary process of moulding. 

The condition of the parts, or the stage of labor at which the operation 
should be performed, is a matter of great importance, less perhaps in 
regard to the mere facility with which it may be effected than with refer- 
ence to the safety of the woman. Although, as has been observed, a 
very moderate dilatation of the os is all that is essential, it affords great 
comparative facility to the operator, and proportionate safety to the 
mother, the further the process of dilatation has advanced. It is of even 
greater importance that the head should have descended, to some extent, 
into the pelvis, and be within easy reach ; for the operation vipon a head 
which is still above the brim will be found, even under circumstances 
which are in other respects favorable, to be a very different operation 
from that in which it is arrested within the cavity of the pelvis. There 
are conditions, however, which may render embryotomy manifestly im- 
practicable, or which may admit of doubt ; so that the peculiarities of 
individual cases must be our guide as to whether anything is to be gained 
by delay, and, if so, to Avhat extent we are to maintain an expectant 
attitude. It is certain that we have less choice here as to the period 
which we may select for the operation than obtains in regard to some of 
the other modes of procedure which we have described. 

The Oj^eration. — Embryotomy almost always involves craniotomy, so 
that the two terms are often used as synonyms. Craniotomy has been 
often euphemistically described as " lessening the bulk of the head." It 
consists of several stages, some of which may alone be required ; or it 
may be necessary, before effecting delivery, to go through the whole of 
them, one after the other. We purpose, therefore, to explain these suc- 
cessive steps, as points in detail of one method of operative procedure, 
according to the degree of pelvic distortion, or other circumstances which 
may constitute the special impediment — and including the use of the 
cephalo tribe. 
33 



514 



EMBRYOTOMY, 



186. 



The first step in all operations of craniotomy is Perforation, and for 
this various instruments have been devised, which are termed perforators. 
The condition of the head, upon which its impaction or resistance de- 
pends, is, in the first place, to be overcome, in order to permit of its col- 
lapse ; and it is with this object solely that we perforate, and so act 
otherwise as to admit of the escape of the contents of the cranium, so 
that the forces, natural or artificial, may be brought to bear upon a part 
which is now susceptible of a considerable diminution in its diameters. 
The form of instrument which has by many Continental 
practitioners been preferred, is one which, in the prin- 
ciple of its construction, is almost identical with the 
ordinary trephine ; but what is preferred and invariably 
used by English operators, is some modification of the 
perforating scissors of Smellie. The instrument here 
shown (Fig. 186) is that which was used by Simpson, 
and which generally bears his name. It consists of 
two blades with shoulder-stops, the blades, when in 
apposition, forming a triangle of which the base is at 
the stops, with cutting edges, converging to a point 
which is the apex of the triangle. The instrument is 
thus one which is to be used with the greatest possible 
caution, lest injury should be inflicted upon the soft 
parts of the mother. When the blades are separated 
by pressing the handles together, a powerful spring be- 
tween the latter causes them to close so soon as the 
grasp is relaxed. 

[The late Professor Hodge used as a perforator a 
pair of scissors having short blades, the longer of which 
measures an inch and a quarter, and the shorter, one 
inch. The blades are very strong, and the longer one 
terminates in a triangular sharp point, which is used as 
a perforator when the handles are closed. The scissors 
may be employed to cut up the bones after perforation 
has been effected. — P.] 
Its mode of application is as follows : The ordinary preliminaries to 
the other operations of midwifery having been carefully observed, the 
woman is to be placed, as usual, upon her left side. Two fingers of the 
left hand are then introduced into the vagina, and brought to bear upon 
the most depending portion of the vault of the cranium. With the 
greatest possible caution, the blades are then to be passed along the 
palmar aspect of these fingers, which serve as a guard to the maternal 
parts, until it reaches the surface of the cranium, through which it is 
thrust by a combined pushing and boring movement as far as the stops. 
While this is being effected, particular attention should be given, so that 
the force be applied at right angles to the surface against which it im- 
pinges, otherwise the point is apt to glance off, and may seriously wound 
the mother. 

Some have advised that perforation should be effected at the sutures or 
fontanelles ; but, although this renders the operation somewhat easier, 
the disadvantage is that the subsequent collapse of the head, by over- 




Sirapsoii's Perforator. 



PERFORATION. 



515 



[Fig. 187. 



lapping of the flat bones of which its vault is composed, will necessarily 
obliterate the aperture, and impede the escape of the cerebral tissue. 
It is, therefore, much better that we should perforate the parietal bone 
which presents ; and, when this has been done in the manner described, 
the handles are pressed together and the blades separated. This, by 
tearing asunder the parts, makes a, lacerated, 
and irregular gap in the cranial walls ; but, 
in order to render the aperture more patent, 
and thus facilitate the escape of the contents, 
the handles are turned so as to bring the 
blades half round, and another similar incision 
is made at right angles to the first. The per- 
forator is then to be thrust into the cavity of 
the cranium, and freely moved about in all 
directions so as to break up, as far as pos- 
sible, cerebrum, cerebellum, and membranes; 
and if the child is alive, it will be proper to 
pass it in the direction of the medulla ob- 
longata, so as to cause its death, as cases have 
occurred in which, after perforation and es- 
cape of a portion of the cerebrum, the child 
has been born alive. The perforator is then 
to be removed with the same precaution as 
was observed on its introduction. If the 
breaking up of the brain has not been satis- 
factorily accomplished, this may be completed 
by the crotchet, which, indeed, some operators 
prefer altogether for tliis purpose, withdraw- 
ing the perforator so soon as the breach in 
the cranial walls has been effected. 

Complete disorganization of the textures 
within the cranium does not necessarily imply 
their immediate expulsion, which can alone 
insure collapse of the cranial vault. This, no 
doubt, has already been in a great measure 
effected by the nature of the aperture which 
we have made in the parietal bone ; but, un- 
less uterine action is present, and can act 
efficiently upon the cranium, the amount discharged, even through a con- 
siderable gap, may be but trifling. In order, therefore, to encourage 
compression, and the consequent diminution of the cranial diameters, it 
has been suu^o-ested that we should extract the brain substance ; and this 
may be effected without danger, and with more or less of success — which 
will be proportionate to the thoroughness with which the cerebral disin- 
tegration has been effected — by a scoop or spoon, or by the injection 
within the cranium of a powerful stream of water. So soon as a large 
portion of the cerebral contents has been permitted to escape, the bones 
of the skull will collapse under the influence of very trifling compression. 
This, however, may completely fail, whence arises the necessity of pro- 
ceeding to another stage of the operation. 




Hodge's Craniotomy Scissors.] 



516 



EMBRYOTOMY 



If nature, after complete decerebration, fails to effect some advance of 
the head, it will then be proper to attempt delivery by traction exercised 
upon any part of it where a secure hold may be maintained. The 
ordinary crotchet, described in a former chapter (see Fig. 179), is the 
instrument which was almost exclusively employed in ancient times, and 
even in the present day is frequently resorted to. The idea here is to 
fix the crotchet upon any part of the bones, and, if possible, at the fora- 
men magnum, or the Sella Turcica, where the best and most effective 
grip may be had, with the least risk of slipping. The directions which 
are very generally given by the older Avriters for the employment of the 
crotchet after perforation, for the purpose of traction, seem to point to 
fixing it upon some part of the inner surface of the parietal bone, and, 
having thus secured a good hold, to drag steadily downwards. The 
great objection to the use of the crotchet in this way is that it is always 
unsafe, and, in the hands of the inexperienced, eminently dangerous. 
No one uses the crotchet for this purpose, unless he has previously passed 
up the finger of one hand in order to protect the soft parts from the 
possible effects of a sudden and unexpected detachment of the instrument, 
which, under other circumstances, would probably inflict upon the mother 
severe, and possibly dangerous, laceration. As it is often difficult effi- 
ciently to protect the parts by means of the finger, an instrument called 
the " guarded crotchet" has been devised. It' is variously constructed, 
but consists essentially of two blades, or rather of a crotchet and a pro- 
tecting blade. In that which is here shown, the crotchet has three sharp 

teeth, and is furnished with the ordi- 
nary forceps joint, by which it is 
articulated with the protecting blade. 
The crotchet, being introduced within 
the cranium, is fixed in the ordinary 



Fig. 1^ 



Fiff. 189. 




manner, and the 



guard 



beino; then 



Guarded Crotchet. Craniotomy Forceps. 



passed in the usual way outside of 
the scalp, the instrument is locked, 
which, so long as this relative position 
is maintained, prevents all possibility 
of laceration by the sharp part of the 
instrument. 

The danger to the mother is, how- 
ever, in point of fact, less from the 
crotchet itself, than from the fracture 
and sudden displacement of the bones 
to which it is attached. Should' the 
tractile force be trifling, the hold 
which the crotchet gives us may be 
maintained ; but if, as is more gene- 
rally the case, we are obliged to use 
a considerable degree of force, it is 
very apt to slip from its attachment, 
or become disengaged in consequence 
of fracture of the bone. It is on this 
account that the o;uard of the crotchet 



CRANIOTOMY FORCEPS 



517 



cannot alone be trusted to, and we must therefore pass up the finger, 
which should be retained in apposition with the head so long as our 
efforts may last, so that we may at once perceive the earliest indication 
of slipping, and adopt such precautions as may be necessary for the pro- 
tection of maternal structures. 

The Craniotomy Forceps (Fig. 189) is, as now constructed, an instru- 
ment which is greatly superior to the crotchet either single or guarded, 
and is applicable to almost all cases in which the latter has been em- 
ployed. When perforation, with evacuation of the cerebral contents, has 
been completed, and it is found necessary to proceed to the further stages 
of the operation, the blades of the craniotomy forceps are to be applied, 
one within and the other without the cranium, that which is convex on 
the outside being for application over the scalp. It will be observed that 
one blade is fitted with sharp teeth corresponding to pits or depressions 
upon the opposed surface of the other. 



Ficr. 190. 



Ficr. 191. 



Fi^. 192. 





Braun's Cranioclast. 



Meigs's Craniotomy Forceps. 



Numerous other forms of craniotomy forceps have been devised, such 
as Braun's cranioclast (Fig. 190), and the simpler instruments which 



518 



EMBRYOTOMY. 



193. 



were employed by Meigs of Philadelphia (Figs. 191, 192), but all forms 
are used pretty much in the same way, one blade being inside the cra- 
nium, and the other outside the scalp. 

When suitably adjusted, therefore, all that the operator has to do is 
to press the handles together with some force, which will insure a grasp 
upon the wall of the cranium, over a more extended area, as well as 
more firmly, than can, under any circumstances, be effected by the 
crotchet. The handles being firmly bound, screwed, or pressed together, 
as the case may be, traction must now be practised in the direction which 
may be proper to the actual position of the head. If the bone gives 
way, the detached portions must be cautiously removed, and a fresh hold 
obtained wherever the parts may seem most likely to bear the strain ; 
but, when the resistance is great, it will soon become evident that this 
method of extraction will fail, and we must therefore pass to a more 
advanced stage still of the operation of craniotomy. 

The process which, under such circumstances, is rendered necessary, 
is the deliberate removal in detail of the flat bones, which require, for 
this purpose, to be broken up into pieces of conve- 
nient size, in order that the whole vault of the 
cranium may be thus removed, including, in ex- 
treme cases, the occiput and the forehead. No 
part of the operation requires more caution than 
the removal of the fractured portions of the bones, 
which are often jagged and splintered, and always 
sharp at the edges, so much so, sometimes, as to 
cut through the cuticle of the fingers of the ope- 
rator, which may afterwards be observed to be 
scarred as if by the edge of a sharp knife. When 
our object is to remove the whole cranial vault, the 
bones are, in the first place, to be broken and sepa- 
rated from their attachments within the scalp — a 
part of the operation which is best efiected by 
means of the craniotomy forceps. In this case, 
however, we introduce the blades somewhat differ- 
ently, passing the outer blade between the scalp and 
the bone, so that the latter is directly grasped. A 
smart wrench by the wrist is generally all that is 
necessary to fracture the bone, when the severed 
portion which remains between the blades may be 
removed by the aid of the instrument. Much will, 
however, depend upon the shape of the fragment, 
which is to be carefully ascertained by the finger 
acting in concert with the forceps. If it is very 
irregular in shape, it ^vill, of course, be all the 
more difficult to protect the soft parts of the mother 
from so many cutting surfaces, and it may be neces- 
sary to divide it again before attempting extraction. The mode of 
grasping the fragment must also be attended to, so as to bring elongated 
portions lengthwise, and in many similar ways we may reduce risk by 
careful manipulation. Dr. Davis was so impressed with the danger wdiich 




Osteotom 



TURNING AFTER CRANIOTOMY. 519 

attends the removal of the fractured cranial bones that he devised an 
instrument, or rather a series of instruments, Avhich he termed Osteoto- 
mists, by which the bones could be more safely removed. One of them 
is here shown (Fig. 193). It is of the nature of a powerful punch, by 
which successive minute portions of the bones may be nipped oif and 
removed in the grasp of the blades, thus completely protecting the soft 
parts. Such an operation was necessarily a very tedious one, and this 
is probably the reason why the instrument was never much employed, and 
has latterly fallen into complete disuse. We have, however, found it to be 
extremely useful in cutting any spicula or sharp angular projections which 
may seem to threaten laceration, and for this reason we look upon it as 
a most useful aid to have at hand when we have to perform the operation 
of craniotomy. By dexterous management, however, we may generally 
succeed in safely removing much larger pieces of bone by the fingers 
than can be efiected by the osteotomist. 

In removing the vault of the cranium, it is proper to preserve the 
scalp. The object of this is to protect the maternal parts from injury. 
It may happen, after a certain amount of progress has been made, and 
a considerable portion of the vault removed, that the head collapses to 
such an extent that the difiiculty is got over, and extraction becomes 
easy. In such a case, the scalp is used as a covering for the bones which 
remain, and as a protection from spicula and sharp edges, which might 
otherwise do mischief. 

If, at any time in the process of removing the bones, or even earlier, 
we are able to seize the forehead by the craniotomy forceps and pull it 
down, this should always be done; but the difficulty in extreme contrac- 
tion is that the vault of the cranium is not yet sufficiently compressible. 
It is mainly, therefore, with the object of ultimately bringing down the 
forehead, which usually lies to the right side, that we thus pick away 
the bones until there remains, when the process is complete, nothing but 
the scalp and the base of the skull. 

There is another method of procedure, not often resorted to, but 
which, in some instances, is of undoubted efficiency after perforation. 
This is the ordinary operation of Turning, which may sometimes be 
effected without much difficulty when, b_y the perforator, we have re- 
duced the bulk of the child's head. To attempt this in cases of very 
great distortion would, on many grounds, be improper ; but in more 
moderate disproportion, it is sometimes an efficient and valuable method 
of completing delivery. A striking instance of this kind, which we saw 
with Drs. Lyon and Dick, was that of a woman in whom it had been 
found necessary to perforate in consequence of very considerable conju- 
gate contraction. Traction with the craniotomy forceps was found to be 
insufficient, and failed to dislodge the head of the child. A considerable 
portion of the bones was then removed, but, before entirely removing 
them, and proceeding to the more advanced stages of the operation, to 
be described immediately, an attempt was made to turn, when, the foot 
being brought within reach, this was effected without the slightest diffi- 
culty. In all such cases, it is of the first importance that the scalp 
should cover the fractured bones, and we should, therefore, be particu- 
larly careful that this should be insured before we attempt to turn. 



520 EMBRYOTOMY. 

The flat bones being removed, the next question for consideration 
which presents itself is one which, without a thorough knowledge of the 
foetal and maternal parts, could not fail to give rise to much doubt and 
apprehension. What remains behind of the head consists entirely of the 
base of the cranium, a part which, even at this early age, is very solid 
and unyielding, in order to afford protection to the vital structures which 
might otherwise be subjected to dangerous or fatal pressure. The shape 
of the base of the skull is that of an irregular ovoid disk, the long 
diameters of which are across the pelvis. It would seem, therefore, at 
first, as if no great advantage had been gained by the removal of the flat 
bones ; but a moment's consideration will show that a very simple ma- 
noeuvre, and one Avhich is generally easy of performance, will suffice to 
place what remains of the head much more favorably. " I have care- 
fully," says Dr. Burns, " measured these parts, placed in diff'erent ways, 
and entirely agree with Dr. Hull, a practitioner of great judgment and 
ability, that the smallest diameter off"ered is that which extends from the 
root of the nose to the chin ; for, in my experiments, — after the frontal 
bones were completely removed, and the lower jaw pressed back, or its 
symphysis divided so as to let its sides be pushed away, — this did not, in 
general, exceed an inch and a half. It is, therefore, of great advantage 
to convert the case into a face presentation." The practice thus recom- 
mended by Burns was at an earlier date upheld by Dr. Osborn, who was 
the first clearly to show that, by canting the base of the skull, so as to 
bring it edgewise into the brim, it was perfectly possible to deliver a full- 
sized child through a conjugate diameter measuring an inch and a half 
only. A very remarkable case, that of Elizabeth Sherwood, which is 
specially interesting as bearing upon the question which we are now con- 
sidering, may here be detailed in a very abridged form. The circum- 
stances of this must, however, have been peculiar, or, possibly, the 
observation of the conjugate measurement was inaccurate. 

The patient was so deformed, botli in her spine and her lower extremities, "as 
never to he ahle to stand erect for one minute without the assistance of a crutch 
under each arm." At the age of twenty-seven she became with child, and was 
admitted a patient into Store Street Hospital, where she was seen by W. Hunter, 
Dennian, and other eminent obstetricians of the day, who gave their sanction to the 
course of procedure, which Osborn ultimately adopted with such remarkable success. 
Dr. Osborn describes his first examination as follows : " Immediately upon the intro- 
duction of the finger, I perceived a tumor, equal in size, and not very unlike in feel, 
to a child's head. However, it was instantly discovered that this tumor was formed 
by the basis of the sacrum, and last lumbar vertebra, which, projecting into the 
cavity at the brim, barely left room for one finger to pass between it and the sym- 
physis pubis,, so that the space from bone to bone at that part could not exceed three- 
quarters of an inch.^'' The operation which was determined upon (a decision which 
gave rise afterwards to no little discussion) was to effect extraction by the perforator 
and crotchet. " Even the first part of the operation, which is in general sufficiently 
easy, was attended with considerable difficulty, and some danger. The os uteri was 
but little dilated, and was awkwardly situated in the centre and most contracted part 
of the brim of the pelvis. The child's head lay loose above the brim, and scarcely 
within reach of the finger, nor was there any suture directly opposite to the os 
uteri." The operation of perforation and decerebration was effected without any 
unusual difficulty, and the patient was then left, as was the general practice in these 
days, for six and thirty hours, in order to allow the uterus opportunity to force the 
cranium downwards as far as possible within the reach of the crotchet, a result which 
was counted upon to some extent, as the effect of putrefactive change. 

" I determined," he continues, " to begin to make an attempt to extract the child. 
I call it an attempt, for I was far from being satisfied in mij own mind of the practicabiliti/. 



ELIZABETH SHERWOOD'S CASE. 521 

My first endeavors were bent to draw the os uteri with mj finger into the widest part 
of the brim of the pelvis, and to dilate it as much as possible. But the removal of 
the OS uteri, and such dilatation of it as the bones admitted, were effected without 
much trouble. I then introduced the crotchet through the perforation into the head, 
and, by repeated efforts, made in the slowest and most cautious manner, destroyed 
almost the whole of the parietal and frontal bones, or the whole upper presenting 
part of the head ; and as the bones became loose and detached, they were extracted 
with a pair of strong forceps, to prevent, as much as possible, laceration of the vagina 
in their passage through it. The great bulk of the head, formed by the base of the 
skull, still, however, remained above the brim of the pelvis ; and from the manner 
in which it lay, it was impossible to enter without either diminishing the volume, or 
changing the position : the former was the most obvious method, for it was a continua- 
tion of the same process, and, I trusted, would be equally easy in execution. I was, 
however, grievously mistaken and disappointed, being repeatedly foiled in every 
endeavor to break the solid boi\es which form the basis of the cranium, the instrument 
at first invariably slipping as often and as soon as it was fixed, or, at least, before I 
could exert sufficient force to break the bone. At last, however, by changing the 
position of the instrument, and applying the convex side to the pubis, I fixed the 
point, I believe, into the great foramen, and by that means became master of the 
most powerful purchase that the nature of the case admitted. 

''Of this I availed myself to the utmost extent; slowly, gradually, but steadily 
increasing my force till it arrived at that degree of violence which nothing could 
justify but the extreme necessity of the case and the absolute inability, in repeated 
trials, of succeeding by gentler means. But even this force was to no purpose, for I 
could not perceive that I had made any impression on that solid bone, or that it had 
been in the least advanced by all my exertions. I became fearful of renewing the 
same force in the same way, and, therefore, abandoned altogether the first idea of 
breaking the basis of the cranium, and determined to try the second by endeavoring 
to change the position. I, therefore, again introduced the crotchet in the same manner, 
and fixing it in tlie great foramen, got possession of my former j^urchase ; then, intro- 
ducing two fingers of the left hand, I endeavored with tliem to raise one side of the 
fore part of the head, and turn it a little edgeways. Immediately and easily suc- 
ceeding in this attempt, the two great objects were at once accomplished ; for the 
position was changed and the volume diminished. Continuing my exertions with 
the crotchet, I soon perceived the head advance, and, examining again, found a con- 
siderable portion of it had been brought into the pelvis. Every difficulty was now 
removed, and, by a perseverance in the same means for a short time, the remaining 
part of the head was brought down and out of the os externum." 

We cannot wonder that the result in this case, and the satisfactory 
recovery of the mother, should have been loolced upon as a great triumph 
of the crotchet as compared with the otherwise inevitable expedient of 
the Cyesarean Section. Of late years this question has been more tho- 
roughly investigated and illustrated. Dr. Braxton Hicks, in a learned 
and elaborate paper,^ describes very fully the mechanism of the pro- 
ceeding. What he recommends is to grapple the orbit and draw it 
downwards by means of a small blunt hook. "The one Avhich I use," 
he says, " is of the following size : the diameter of the iron rod from 
which it is made is about a quarter of an inch, of the length of the ordi- 
nary blunt hook; with handle also alike. The hook is a half circle about 
one inch in diameter, and is made hard, to prevent its opening during 
traction ; the shaft is made of soft iron, and can be bent by the hand into 
any form, being thus adaptable to any situation. I may mention here 
that this hook is useful, in other cases, in a variety of ways, where it is 
impossible to employ the unwieldy blunt hook in general use." 

Dr. Barnes, after removing the arch of the calvarium, or the whole of 
the bones if the distortion be extreme, prefers, for effecting the same 

1 Obstetrical Transactions, vol. vi. 1865, p. 263. 



522 



EMBRYOTOMY 



object, the craniotomy forceps. The instrument which he uses is of con- 
siderable strength, and is provided, like Braun's, with a screw at the 
ends of the handles, which secures for it the ordinary advantages of the 
cephalotribe,by crushing in the frontal bones, and has the further advan- 
tage of securing an unyielding hold. "Then traction is made, carefully 
backwards at first, in the course of the circle round the false promontory. 
As the face descends it tends to turn chin forwards, and this turn may be 
promoted by turning the handles of the instrument. It is not necessary 
that the turn should take place, for the case differs entirely from that of 
the normal head. There is no occiput to roll back upon the spine between 
the shoulders. The head comes through flatwise like a disk by its 
edge." 

The above extracts, which represent the most modern and scientific 
modes of practice, will suffice to prove that where the pelvis measures 
tiuo inches^ or even somewhat less, in the conjugate diameter, a fully 
developed child may yet possibly be extracted. It is obvious, however — 
the transverse diameter of the face being more considerable — that, to 
insure success, there must be a larger space, certainly not less than three 
inches in the transverse diameter. '' I go further," says Barnes, in 
reference to this operation, ••' and declare that it is perfectly unjustifiable 
to neglect this proceeding, and to cast the woman's life upon the slender 
chance afforded by the Caesarean Section." 

The Cephalotribe. — If the facts and arguments above cited are strictly 
correct, the number of cases in which the cephalotribe is called for are 
probably very limited in number. They are cer- 
tainly much more so than was. at one time supposed. 
The earliest instrument designed for crushing the 
bones of the foetal skull seems to have been the 
Compressor Forceps of Assalini, which was used by 
him to crush the base of the skull and the face, 
early in the present century. The blades of this 
instrument were not made to cross, so that when they 
were screwed together, the fulcrum of each lever was 
— as in his forceps — the joint at the end of the 
handles, where they were articulated. The only 
modern instrument resembling this in principle is the 
cephalotribe of Lazarewitch of Charkoff. What, 
with certain modifications, is known as the French 
cephalotribe, was invented by the younger Baude- 
locque. It is, in appearance, a most formidable 
instrument ; the one in our possession weighing no 
less than 4 lbs. 6J oz., and measuring across the 
blades nearly two inches, in the widest part. It 
requires, therefore, no argument to show that such 
an apparatus is not applicable to a case like that of 
Elizabeth Sherwood. Various modifications have, 
in modern times, been designed by Scanzoni, Braun, 
Simpson, and others, almost all of which are con- 
structed with a moderate degree of pelvic curve. They are all made 
lighter than the original instrument, as it has been found that clumsiness 



194. 



^VWtMM.WUMSI^ 



Simpson's Cephalotribe. 



THE CEPHALOTRIBE. 



523 



may be, to some extent, avoided without any material sacrifice of strength. 
The tendency of the English instruments is to approach more in form to 
the ordinary midwifery forceps, as is well shown in Simpson's cephalo- 
tribe, which is here represented (Fig. 194). 

As in the case of the forceps, there has existed in this country some 
controversy as to whether the pelvic curve should or should not be adapted 
to the cephalotribe, those who approve of the straight instrument arguing 
with some force that the straight blades are easier of application, and 
can alone be properly applied when we wish to rotate. The fact that the 
head is at the brim seems to us, on the contrary, to vindicate, on the same 
grounds which have been urged with reference to the long forceps, that 
unless we are, as Pajot and some others advise, 
absolutely to discard the instrument as an ex- Fig. 195. 

tractor, we must admit that the principle of the ^ 
pelvic curve ought to be conceded here also. The 
objections which Dr. Kidd and others have urged 
against the pelvic curve have, however, so far 
prevailed, that the English instruments are all, 
without exception, made with a slighter curve than 
the French ones. 

The French cephalotribes (Fig. 195), still re- 
tain, as we have said (and, we may add also, the 
German modifications of Braun and Scanzoni), 
much of the original formidable dimensions of the 
instrument. We might have contented ourselves 
with the mere mention of this fact were it not that 
of late years some able obstetricians have con- 
demned the English instrument, and insisted that 
we should do better to adhere more closely to 
French models in the construction of cephalotribes. 
Dr. Matthews Duncan, assisted by Professor In- i 
glis, of Aberdeen, and others, made some very 1 
interesting experiments with a view of comparing ^^^ 
the effects of Simpson's cephalotribe and the more 
modern of the French instruments. The experi- 
ments were performed on foetal crania, and on the 
skulls of dogs, and certainly served very clearly 
to demonstrate that the French cephalotribes have 
greater power. Are we, therefore, on that ac- 
count, to prefer them, to the exclusion of those 
with shorter handles ? 

In reply to this question. Dr. Duncan expresses 
a decided preference for the French cephalotribe, Frencii Cephalotribe. 

a modification of which he has devised, so as to 

combine the lesser degree of pelvic curve which is characteristic of Eng- 
lish instruments, with certain other modifications which he considers as 
offering some advantage. Dr. Duncan's cephalotribe is here represented. 
Drs. Barnes and Braxton Hicks are, again, warm supporters of what we 
have termed the English cephalotribe, and while they do not assert that 
the crushing force is equal to that of the French instrument, they main- 




524 



EMBRYOTOMY. 



Fig. 196. tain that the power is attained in sufficient perfec- 

tion for the object which we have in view, and that 
there is a gain in the facility of handling, which 
may be held as sufficient to counterbalance any 
trifling loss of power. 

We have at present to consider the subject of 
Cephalotripsy as the final stage of the operation of 
craniotomy in cases of great pelvic contraction. 
Perforation, decerebration, removal of the flat 
bones, and cantino; edo;ewise of the base of the 
skull have all, we shall suppose, been successively 
tried, but to no purpose. Can anything further, we 
ask ourselves, be done in this same direction ? — a 
question which finds its reply in the operation which 
we are now considering. The object of the instru- 
ment is, as its name implies, to crii^li the unyielding 
base into a pulp, and thus bring it through the con- 
tracted diameters. The blades are introduced in the 
same manner as those of the ordinary long forceps, 
in the direction in which there is least resistance, 
which will generally be the sides of the pelvis. They 
are passed high up, so as to reach quite beyond the 
base, which it is our object to crush ; and, being 
adjusted, the screw is then turned steadily and 
cautiously, while the finger within the vagina takes 
note of what is being done, and is ready to remove 
at once any spicula of bone which may crop up 
under the influence of the crushing force. What- 
ever form of instrument we may choose, it should 
be one which does not measure, when closed, more 
than an inch and a half outside the widest part of 
the blades. This admits, therefore, of such crush- 
ing as may enable the head to pass through a 
diameter which may be contracted to that extent. If the deformity is 
great, a second crushing may be necessary, and, for this purpose, the 
blades should be removed and re-introduced, so as to secure a grasp which 
should be, as nearly as possible, at right angles to the first. 

It must not be supposed that it is only to cases in which the Avhole of 
the flat bones have been already removed that the operation of cephalo- 
tripsy is applicable. On the contrary, it may often be used with advan- 
tage when only a portion of the vault has been got away. This is gene- 
rally sufficient to admit of the easy introduction of the blades, so that, 
if mmsual difficulty is experienced in extracting the bones, and the head 
refuses to advance under steady traction, the operation Avill have the 
double effect of crushing the base and permitting the collapse of the skull, 
and complete escape of all its contents. In this case, however, we should 
watch with special caution the efi"ect of the compression upon the cranium, 
otherwise the maternal parts may, at any moment, be wounded by frag- 
ments of the tabular bones. 




Dr. Matthews Duucan's 
Cephalotribe. 



THE CEPHALOTEIBE. 525 

A subject which has given rise to no little discussion, is whether or not 
we should, after crushing, use the cephalotribe as a tractor. Pajot con- 
demns such a course, and recommends a procedure which he describes as 
" cephalotrijjsie repette sans tractions,''^ in which he leaves expulsion ab- 
solutely to nature. He also recommends, what, if feasible, is certainly 
advantageous — that we should rotate the head which has been operated 
upon, so as to bring its crushed diameter in relation with the contracted 
diameter of the pelvis. This condemnation of the cephalotribe as a 
tractor, seems chiefly to be supported by those who, in France or else- 
where, uphold the use of the bulky instruments which are very obviously 
less suitable for such a purpose. What seems, therefore, to be the chief 
advantage of the lighter English instrument, is that traction may b}^ it 
be more safely performed. Indeed, it appears to us in the highest de- 
gree irrational that we should forego all the advantages of traction which 
spring from such a firm grasp of the head as the cephalotribe gives. We 
cannot, indeed, be too cautious in our manipulations ; but, we can see no 
reason why, after efiicient crushing, we should not pull gently with the 
handles backwards, which we can, of course, do with more safety, and a 
greater advantage, than if there was no pelvic curve to the blades. An- 
other disadvantage of removing the blades, and leaving the further pro- 
gress of the case to nature, is said by Dr. Barnes to consist in the re- 
siliency of the foetal structures ; so that a head flattened within the grasp 
of the cephalotribe so as to measure not more than an inch and a half, 
may spring out on the removal of the blades to more than two inches. 

When the mutilated head at length glides through the chink which has 
so obstinately barred its progress, the young operator may hastily con- 
clude that his difficulties are necessarily at an end. In cases of minor 
disproportion, it will no doubt be so ; but, in extreme distortion, the de- 
scent of the shoulders and trunk may be attended with very considerable 
difficulty. If the remains of the head be still within the grasp of the 
cephalotribe, it is proper to continue the tractile force backwards, as far 
as may be practicable with a due regard to the integrity of the perineal 
structures. This is done with the view of disengaging the anterior 
shoulder, or bringing it a little in advance, so that the blunt hook may be 
fixed in the axilla to pull it through. It may be necessary at this stage, 
when the blunt hook and crotchet fail to eff'ect delivery, that the cephalo- 
tribe should be again used, and the trunk crushed prior to delivery ; a . 
proceeding which, although rarely necessary, is certainly preferable to 
the employment of such violence as might otherwise endanger the tissues 
of the mother. 

There are cases in which it is found necessary to lessen the bulk of the 
head in breech presentations, or after turning, the head being arrested 
after the trunk has been successfully disengaged from a contracted pelvis. 
In this case, the conditions of the operation are inverted, but are not by 
any means, as a rule, more difficult. Perforation may be effected behind 
the ear, and this situation should be selected as the point at which we 
may most readily attain the cavity of the cranium, and give exit to the 
brain substance, so as to permit of the collapse of the head. In this 
case also, the cephalotribe may be employed with great advantage, by 
crushino; the base of the skull, which in this instance is in advance of the 



526 EMBRYOTOMY. 

vault ; and, if the measurements are such as to have already admitted 
of turning, or of the descent of the breech, we may be almost sure that 
the collapse of the head which must now necessarily ensue, will amply 
suffice to permit of its passage through the pelvis. 

Emhryulcia. — When some part of the child other than the head pre- 
sents, it may be requisite to use the perforator upon the trunk, and en- 
deavor to extract the child by the evacuation of the contents of the thorax 
and abdomen. This is one of the methods, for example, which have been 
practised in cases of transverse presentation in which turning is imprac- 
ticable. There is no difficulty in such a case in making a breach in the 
thoracic walls, below the axilla, of sufficient size to admit of the removal 
of the lungs and heart, and, subsequently, by perforation of the diaphragm, 
of the abdominal viscera — the most important of these being the liver, 
which, as is well known, is of great size in the foetus. The breaking up 
of the organs prior to their removal cannot be effected in the same bold 
manner as in craniotomy, as we might easily perforate the trunk, and 
wound the walls of the uterus. After thus reducing the bulk of the 
trunk, what should now be attempted is an imitation of the natural pro- 
cesses of spontaneous evolution, or spontaneous expulsion, which maybe 
effected by forcibly dragging down the breech, by the blunt hook or 
otherwise, after the organs have been removed. This, hoAvever, is not 
always easy ; and we have a vivid recollection. of such a case, which Ave 
saw many years ago, where turning had been found impracticable, and 
embryulcia had been practised to the extent of removing the whole of the 
abdominal and thoracic organs. The crotchet and blunt hook were re- 
peatedly fixed upon the pelvis and lower vertebrae, but without success, 
and the woman ultimately died undelivered. Looking back upon this 
case with the vividness with which memory recalls early experiences, we 
feel assured that the treatment proper to it ought to have been decapita- 
tion, and not evisceration. 

Decapitation has been described in a previous chapter, and should, we 
believe, be always taken into consideration when the question of embry- 
ulcia in impacted transverse presentation crops up. Evisceration is not, 
however, limited to cases of transverse presentation, but may be found 
necessary, and has often been practised as a sequel of craniotomy, when 
it may be requisite to diminish the bulk of the trunk, on precisely the 
same principle as has guided us to perforation of the cranium at an earlier 
stage of the operation, where we cannot succeed in delivering by the 
blunt hook, crotchet, or any other instrument which we may employ 
purely for the purpose of traction. It is probable, how^ever, that under 
such circumstances, the process previously detailed, in which the cepha- 
lotribe is the agent employed, might be adopted with a better prospect of 
satisfactory results. 

A very powerful instrument, but one rather complicated in its construc- 
tion, is that which was invented by Van Huevel, of Brussels, and has 
subsequently been adopted by some eminent Continental practitioners as 
a substitute for the crotchet, cephalotribe, and other instruments which 
we have described as essential to the performance of craniotomy, under 
any circumstances which may involve greater difficulty than usual. This 
instrument is known as Van Huevel's Forceps Saw, and consists in the 



Barnes's process. 527 

first place of forceps, of which the blades are of unusual strength. On 
the inner aspect of the latter is a groove extending from aboat one inch 
below the extremity to near the lock. Within the groove, and protected 
by a band of steel, the chain saw is introduced after the blades have 
been adjusted, and is then made to cut from without inwards, or from the 
lock towards the tips of the blades, until the head has been divided — the 
chain being worked by two small cross handles at its extremities, while 
its action, protected by the blades of the forceps, may be looked upon as 
absolutely safe. 

Dr. Barnes has lately suggested another operation, by which the wire 
^craseur may be used for the purpose of bisecting the head, or otherwise 
operating upon the body of the foetus. This method of performing Em- 
bryotomy was demonstrated by the inventor before the Obstetrical Society, 
the instrument employed being the ecraseur of Braxton Hicks. He re- 
commends the employment, not of the wire rope suggested by Hicks ,^ 
but of a single loop of strong steel wire, which he manipulates, so as to 
pass it through the cervix uteri and the chink of the pelvic brim. The 
crotchet being passed into the hole made by the perforator, and held by 
an assistant, so as to steady the head, the loop is guided over the crotchet 
to the right side of the uterus, where the face lies. " The compression 
being removed, the loop springs open to form its original ring, which is 
guided over the anterior part of the head. The screw is then tightened. 
Instantly the wire is buried in the scalp ; and here is manifested a singu- 
lar advantage of this operation. The whole force of the necessary 
manoeuvres is expended on the foetus. In the ordinary modes of per- 
forming embryotomy, as by the crotchet especially, and in a lesser degree 
by the craniotomy forceps and cephalotribe, the mother's soft parts are 
subjected to pressure and contusion. The child's head, imperfectly re- 
duced in bulk, is forcibly dragged down upon the narrow pelvis, the 
intervening soft parts being liable to be bruised, crushed, and even per- 
forated. And this danger, obviously increasing in proportion to the 
extent of the pelvic contraction, together with the bulk of the instruments 
used, deprives the mother, in all cases of extreme contraction, of the 
benefit of embryotomy, leaving her only the terrible prospect of the 
Csesarean Section. When the anterior or posterior segment of the head 
is seized in the wire loop, a steady working of the screw cuts through 
the head in a few minutes. The loose segment is then removed by the 
craniotomy forceps. In minor degrees of contraction, the removal of one 
segment is enough to enable the rest of the head to be extracted by the 
craniotomy forceps. But in the class of extreme cases, in which this 
operation is especially useful, it is desirable still further to reduce the 

' We have frequently employed this instrument for the removal of uterine polypi, 
and in other similar operations, but have found that the wire ropes suggested by the 
inventor are not to be depended upon, and are apt to snap under a powerful strain. 
Tliinking at first that this was due either to some imperfection of the instrument, or 
to some fault in the annealing of the wire of which the rope was composed, we con- 
sulted Dr. Hicks, who was so obliging as to order a complete instrument and ropes, 
after his own model ; but the result was still far from satisfactory. Fi'om the expe- 
rience we have since had of the single steel wire suggested by Dr. Barnes, we are 
inclined to give it a decided preference. 



528 HYSTEROTOMY, 

head, by taking off another section. This is best done by re-applying 
the loop over the occipital end of the head." 

A word may here be added as to the probable range of cases within 
which the cephalotribe may be applied. Much will, of course, depend, 
as has already been observed, upon the degree of contraction, not only 
of the conjugate, but of the other diameters of the pelvis. In a discus- 
sion on this subject, held at Berlin, the majority of the speakers thought 
that a minimum of two inches in the conjugate diameter was necessary. 
Crede, Pajot, Hicks, and Barries have however encountered cases in 
which the contraction ranged from one and three-quarters to one and a 
half inches, and have yet been able successfully to accomplish the opera- 
tion. It is important that facts such as these should be borne in mind 
when Ave have to consider the dernier ressort of operative midwifery — • 
the Csesarean Section — which will form the subject of the following 
chapter. 



CHAPTEE XXXIII. 

HYSTEROTOMY AND ALLIED OPERATIONS. 

History of the Operation of Hysterotomy. — Cases in' which it is Justifiable. — 
Maternal Mortality. — Different Results in British and Continental Practice. 
— Conditions favorable to Success. — The Operation and its Details: Duties of 
the Assistants : Closure of the Wounds. — After-Treatment. — Causes of Fatal 
Result. — Effect of Cold in preventing Peritonitis. — Repeated Success of the 
Operation in the same Cases. — Gastrotomy: Cases in tvhich the Operation is 
required. — The so-called Vaginal Ccesarean Section. — Symphysiotomy : 
History and nature of this Operation: Objections to it. — Stoltz's Operation of 
Pubiotomy. — Gastro-Elytrotomy ; reasons which have been urged in its 
favor. — Tabidar Statement shoiving the Degree of conjugate Contraction at 
the Brim, which may be supposed to indicate respectively the Operations of the 
Long Forceps., 7\irning, Embryotomy, and the Ccesarean Section. 

Hysterotomy or, as it is more familiarly known, the Ccesarean Sec- 
tion, is an operation whereby the foetus is extracted through an opening 
which is made in the abdominal and uterine walls. The propriety of such 
a procedure, in the case of the sudden death of the mother, is in the 
hope of extracting a living child, so obviously a course to which no ex- 
ception can be taken, that nothing need be urged in justification of the 
operation in the abstract. 

From the earliest period in the history of midwifery, it had been occa- 
sionally practised on women dying during labor ; and the names of 
Scipio Africanus, Manilius, Andria Doria, and others, are recorded as 
having been brought into the world under such circumstances, in obe- 
dience to the law of Numa, which forbade the burial of a pregnant 



JUSTIFIABLE CASES. 529 

woman in whom the operation had not been performed. About the end 
of the sixteenth or the beginning of the seventeenth century, it would 
appear that the operation had been performed in cases in which the child 
had escaped into the cavity of the peritoneum ; but as this proceeding is 
not, properly speaking, the Caesarean Section, these cases are only to be 
regarded as instances of Laparotomy or Gastrotomy. It is not precisely 
known at what epoch Hysterotomy was first performed on the living 
woman ; for there is every reason to believe that the cases published by 
Rousset in 1581 were to be referred chiefly to the preceding category. 
The publication of Rousset's work, celebrated in the history of the sub- 
ject, gave rise to the most extravagant expectations, and at one time the 
operation was so recklessly performed by surgeons, that it was only by 
the uncompromising attitude of Guillemeau and Ambroise Pare that it 
fell into disfavor. It is of this period that Scipio Merunia spoke when 
he talked, with pardonable exaggeration, of tlie operation being as com- 
mon in France as bleeding in Italy. The opposition thus encountered in 
such influential quarters had well nigh condemned the Cc^sarean opera- 
tion to oblivion ; but it was again revived, and gave rise to endless and 
bitter discussion during the whole of the seventeenth, and, we may add, 
the first half of the last century, without anything definite having been 
elicited or determined upon, the profession being divided into two par- 
ties, one of which condemned the operation in the most uncompromising 
way, while the other as warmly, and with even less of discretion, was 
enthusiastic in its support. It will be observed, therefore, that the Cse- 
sarean Section, as now calmly looked upon in the light of science, dates 
from quite modern times. 

While it must be admitted that every step in advance Avhich has been 
established by conservative midwifery throws further into the shade the 
sacrificial or more desperate operative resources of the art, there proba- 
bly exist no practitioners in the present day who will not admit that there 
are cases in which hysterotomy is justifiable on grounds which will stand 
the test of the strictest scientific examination. Putting aside, for the 
moment, the cases in which it may be practised upon the dead, it may be 
broadly asserted that the operation is called for on the living in all cases 
in which the state of parts is such as to preclude the possibility of de- 
livery by embryotomy. In other words, we are driven to this last 
resource whenever we recognize the fact, that the foetus, however muti- 
lated, cannot be extracted by the pelvic canal. 

Considerable difierence of opinion unfortunately exists as to the limit 
of contraction which will warrant the performance of Hysterotomy. In 
Germany, it is very generally asserted that two and a half inches, in the 
conjugate of the brim, is to be held as the limit in question; but there 
are, in so far as we are aware, none in this country who endorse this 
view. What has already been said in the preceding chapter aflbrds 
ample proof that Craniotomy may be successfully performed in contrac- 
tions of one inch and three-quarters ; and the experience of some of the 
most distinguished of modern operators seems to show that this limit may 
be reduced to one inch and a half. AVe may say, then, confidently, that 
when the conjugate diameter exceeds these limits, we are in no case jus- 
tified in at once deciding in favor of the C^esarean operation. We must 
34 



530 HYSTEROTOMY. 

once more, however, reiterate a former observation, and call attention to 
the fact that the conjugate measurement is not alone to be taken into 
account — as it is too much the fashion to do — seeing that we may have 
irregular or angular distortion, in which the other diameters are similarly 
or, it may be, chiefly distorted. And it is a point of very great interest 
and importance that, of the whole number of reported cases of hyster- 
otomy, a large majority were due to osteomalacia, in which, as we have 
seen, the typical distortion does not necessarily involve the conjugate 
diameter at all. A much smaller number were cases of rickets ; and, 
among the rarer conditions calling for the operation, may be mentioned 
exostosis, fracture of the pelvis, spondylolysthesis, fibrous or other 
tumors, and carcinoma of the os and cervix. What we wish, therefore, 
more particularly to notice is that the conjugate measurement cannot be 
accepted as the test of the necessity which may be assumed to exist for 
the performance of this operation. 

The maternal mortality in this country has been so great — not less than 
85 per cent, of all recorded cases — that a very general idea prevails that 
this is almost exclusively a child's operation. This is a double error ; for, 
when we perform the operation, in a case where we know that the child 
cannot be otherwise born, we give the mother the chance, small though it 
be, of recovering from the effects of the operation, while otherwise we 
must leave her to die ; and, as regards the child, the results are far from 
being so favorable as to warrant us in looking upon it as a child's opera- 
tion, although it may, no doubt, fairly be inferred that this is attributable 
in some degree to the fact that the operation is often delayed too long. 

If we turn for a moment from British to Continental statistics, it must 
be admitted that the results are vastly more favorable in the latter case. 
The reason of this is obvious, and has its origin directly, or indirectly, in 
the greater regard for foetal life, which, on religious grounds, causes 
hysterotomy to be looked upon with more favor than embryotomy. Du- 
bois says, for example, that when the brim is contracted to two inches, 
and the child is living, we should choose the former operation without 
hesitation. His authority, therefore, and that of others of equal dis- 
tinction, has necessarily led to the performance of hysterotomy in a larger 
proportion of cases than has ever obtained in this country. Moreover, 
the very anxiety to save the child leads to the performance of the opera- 
tion at a much earlier period of labor than is practised in this country ; 
and we cannot doubt that it is this which brings about their successful 
results. It is, indeed, of vital importance that the operation should not 
be delayed until symptoms of exhaustion have set in, as has been too often 
the case in England, — although we operate, primarily at least, in the in- 
terests of the mother, and with a mere secondary consideration for the 
life of the child. It is difficult to avoid the conclusion — in which w^e have 
the support of Cazeaux — that the operation is rashly undertaken, by many 
of our Continental brethren, in cases Avhere the proper operation is em- 
bryotomy. This is one of many causes which should encourage us to 
give to the subject of embryotomy our best and most earnest considera- 
tion, that wx may, by perfecting that operation, reduce more and more 
the necessity for having recourse to hysterotomy. If we admit the re- 
ligious element into the question, our difficulties are inevitably increased. 



MATERNAL MORTALITY. 531 

Or, should we give force to such considerations as are suggested by Den- 
man — that we should gravely consider, whether, in the case of a woman 
who, knowing that she cannot bear a living child, has allowed herself to 
become pregnant, we should not act rather in the interests of the child — 
or, in other words, if we weigh the life of the child as of equal importance 
in any case with that of the mother, we will speedily become bewildered 
in the mazes of casuistry, and may be led to do what is morally wrong. 
In a word, hysterotomy is no exception to the general rule that we should 
act primarily in the interests of the mother. 

When the operation is called for by the death of the mother, either 
before or during labor, there are no considerations which will encourage 
a moment's hesitation or delay. During labor, it may be possible to turn 
and deliver, or to extract by the forceps almost as rapidly as to remove 
the child through the abdominal walls, — and this proceeding has the ad- 
vantage of being less repugnant to the feelings of relatives and friends ; 
but, if the OS is not sufficiently dilated, or if labor has not commenced, we 
have no choice in the matter, the only rule being to extract the child with- 
out unnecessary delay. The period during which the vitality of the child 
may be preserved is probably very limited. Authentic cases are recorded 
in which the child has been removed alive ten, fifteen, and even thirty 
minutes after the death of the mother ; but we must treat as fables those 
instances of which we read, where it is said to have been found alive ten, 
fifteen, or twenty-four hours after the mother had ceased to live. In 
death before the seventh month, it would be a manifest impropriety to 
operate ; bat religious convictions have caused this to be done in order 
that the child may have the benefit of Christian baptism. 

The Coesarean operation is, however, under certain circumstances, im- 
peratively demanded while the mother still lives. Let us see, therefore, 
what are the conditions upon which success will mainly depend. The 
first, and perhaps the most important point, is the early recognition of 
the nature and extent of the obstruction. This will enable us to prepare 
the woman, in some degree, for the great peril to which she is about to 
be subjected, by careful attention to the bowels and so forth. It is a 
matter of doubt, whether we should wait for the coming on of labor, or 
induce it artificially. There are arguments in favor of both modes of 
procedure, but perhaps the safest plan will be to Avait until nature gives 
evidence that she is about to call upon the uterus to assume its physio- 
logical action, which will be an assistance to the operator at certain stages ; 
and, besides, we are entitled to assume that, at the full time, the healing 
process is more likely to be encouraged by the normal physiological phe- 
nomena of involution. Under no circumstances should we operate until 
the OS has opened to some extent, so as to permit of the discharges pass- 
ing by the normal channel ; but, if it be thought advisable to precipitate 
matters, this can always be done by some of the ordinary modes of pro- 
cedure for bringing on premature labor. Winckel says that the most 
favorable period for the operation is the end of the first stage ; and he 
recommends that we should not rupture the membranes, as some have 
done, with the view of permitting the escape of the liquor amnii. 

The Operation. — The measures to be taken before commencing the 
operation should be those which the most experienced of our ovariotomists 



532 



HYSTEROTOMY. 



have found, of late years, to be conducive to success. The patient should 
be placed upon a high bed or table, in a good light, with her shoulders a 
little elevated. The temperature of the room should, if necessary, be 
artificially raised. The operation should be performed under the car- 
bolic spray and with the most scrupulous attention to all the details of 
antiseptic surgery, precisely as in a case of modern ovariotomy. There 
should be at hand an abundant supply of hot and cold water, and a suffi- 
ciency of towels and sponges. Several bistouries, with sharp and blunt 
points, artery forceps, ligatures of various kinds (including antiseptic 
cat-gut), bandages, carbolized dressings and a long probang, will, with 
the usual minor instruments of an ordinary pocket-case, be all that is 
necessary. The propriety of giving anaesthetics in this operation has 
been called in question, chiefly on account of the disastrous effect which 
an attack of retching might have at a critical moment of the procedure ; 
but, if the stomach is empty before these agents are administered, the risk 
is not likely to be great. The operator, standing in front of the patient, 

Fig. 197. 




Hysterotomy. 



and having ascertained that the bladder is empty, must first examine the 
abdominal walls, in order to ascertain, with precision, the position of the 
uterus with reference to them. A final examination, per vaginam, should 
also be made, as some cases of osteomalacia have been recorded in which 
the bones of an extremely distorted pelvis have yielded so much as to 
admit of the passage of the hand. The primary incision is to be made 
in the middle line, and should extend from a little below the umbilicus to 



UTERINE INCISION.. 533 

about two and a half inches above the pubic symphysis. Further than 
this it would be imprudent to go in the latter direction, and, in the case 
of extreme deformity or unusual shortness of stature rendering a larger 
incision necessary than can be effected by this rule, the wound should be 
commenced above, and a little to the left of the umbilicus. The knife 
should be carried through the skin and subcutaneous cellular tissue, and 
the various aponeurotic layers successively divided, until the peritoneum 
is reached. Any bleeding vessels should be carefully secured before 
going further. 

The uterus having been previously adjusted, so as to bring its axis as 
nearly as may be into parallelism with the abdominal incision, the hands 
of two assistants are now to be placed above and below, with the view of 
bringing the uterine and abdominal walls into close apposition, and thus 
maintaining their relative positions until the operation has been completed. 
The section of the peritoneum should be effected with caution, not only 
with the view of protecting the subjacent uterine tissue, but also to avert 
the possibility of w^ounding the bowel, as cases have been known in which 
convolutions of the small intestine were lodged in front of the uterus. 
When the peritoneal cavity has been opened in this manner, the operator 
should introduce, through the first minute incision, a director, upon which 
he may cut ; or having made an aperture sufficient to admit of the passage 
of the forefinger, that may be advantageously used as a director, along 
the palmar surface of which a blunt pointed bistoury may be passed. 
During the whole of this process, the attention of the assistants should 
be sustained, so as to prevent the possibility of protrusion of the bowels, 
while any discharge should be assiduously removed by means of sponges 
wrung out of carbolic solution. 

The surface of the uterus beino; now brought into view, the next stao;e 
of the operation consists in the section of its walls. It has been said 
that the site of the placenta may be determined by auscultation, a bulging 
of that portion of the uterine wall, and by certain other signs to which 
it is unnecessary to refer ; but we do not believe that any of these signs 
are such as may be depended upon, so that the exact situation of the 
placenta must remain, in some degree at least, doubtful. The uterine 
incision is to be made in the middle line, so as to correspond to that in 
the abdominal walls, and is to be carried cautiously through the perito- 
neum and proper tissue of the organ, so as to avoid the fundus and cervix ; 
the reason bemg that the section of the circular fibres there situated 
would be extremely likely to cause a gaping of the wound. As the knife 
approaches the inner surface of the uterus, we must exercise some caution 
lest we injure the placenta, which may be immediately subjacent; and if 
it should chance that this structure intervenes between us and the embryo, 
Vte must carefully insinuate the fingers between the placenta and the 
uterine wall, until we reach the margin of the former, before attempting 
to extract the child. 

If — as is usually considered a favorable condition at this stage — the 
membranes are intact, the escape of the liquor amnii must be guarded 
against at the moment of perforation. For this purpose, the aperture in 
the membranes should be made as minute as possible, and an assistant 
specially detailed for this duty should carefully receive in sponges the 



534 HYSTEROTOMY. 

fluid as it escapes, so as to prevent its entrance into the cavity of the 
peritoneum. An orifice of sufficient size being thereupon made, the 
extraction of the child is to be effected with the least possible delay, the 
feet being seized, and delivery promptly completed. While this is being 
done, a certain amount of uterine contraction will usually occur, which 
is an additional reason for speedy action on our part ; otherwise, the 
breach in the uterine walls will become rapidly diminished in size. It 
has not unfrequently happened that, when the body of the child has been 
successfully extracted, the contraction has been so rapid as to cause the 
neck to be so firmly grasped as to prevent the completion of the operation, 
a state of matters in which it is better to enlarge the incision, than to use 
force, by which we can only succeed by tearing open the wound. 

If the placenta is not at once detached, the hand should be imme- 
diately introduced into the cavity, and the organ separated from its 
attachments, and extracted as the hand is being withdrawn. The chief 
risk of the operation at this stage is, of course, the hemorrhage which 
necessarily occurs from the uterine sinuses which have been cut through, 
as well as from the inner surface of that portion of the organ from which 
the placenta has been separated. The former is the source from which 
bleeding is chiefly to be looked for ; but experience has shown that this 
risk IS very much less than might have been anticipated, the actual amount 
of discharge depending, in a great measure, on the efficiency of the ute- 
rine contractions ; and it is certain that, fatal as the operation is in its 
results, death rarely ensues from hemorrhage. The greatest care on the 
part of the assistants is necessary, in order to prevent the entrance of 
the blood and other discharges into the cavity of the peritoneum, and 
the escape from it of the intestines. Perfect success in this direction is, 
of course, impracticable ; but we may be sure that the less the quantity 
of such discharges that comes in contact with the peritoneal membrane, 
the less likely is the dreaded peritonitis to be severe or fatal in its cha- 
racter. The use of antiseptic precautions, as regards the fingers, instru- 
ments, sponges, and otherwise, will further reduce this risk. The escape 
of the intestines may be prevented, and the approximation of the uterine 
and abdominal walls efficiently maintained, by an expedient which was 
suggested by Winckel. This consists in having the extremities of the 
uterine wound hooked upwards by the finger, and thus brought into con- 
tact with the walls of the abdomen, a manoeuvre which is peculiarly appli- 
cable to cases in which the number of assistants is deficient. The pro- 
bang should finally be passed downwards through the os uteri to the 
vagina, which insures for the discharges free egress by the normal 
channel. 

Delivery having been by these means effected, the mode of closure 
and general management of the incisions, uterine and abdominal, is the 
subject which next engages our attention. When the uterus has well 
contracted — a process which is materially hastened by pressure of the 
organ, and even by the application of cold — when all bleeding has ceased, 
and when the discharges have been wiped away as thoroughly as possible, 
the edges of the wounds are to be brought into apposition. It is a matter 
of dispute whether we should or should not stitch the uterine wound. 
It is quite certain that this is not essential to success, and it is doubtful, 



CLOSURE OF THE WOUND. 535 

as may be inferred from the experience of Winckel, whether or not it is 
in any way beneficial. Still, on ordinary surgical principles, and recog- 
nizing the fact that, in a certain number of fatal cases, the wound has 
been found gaping after death, we cannot wonder that most operators 
seek in this way to promote union of the uterine tissues. But for one 
circumstance, the most advantageous procedure would be to bring the 
uterine and abdominal wounds into close apposition by the same suture ; 
but the circumstance in question is a most important one, and depends 
upon the contractility and natural involution of the uterine tissue, which 
would probably involve forcible dragging upon the wound. To effect 
closure of the uterine incision by means of suture, while the risk referred 
to is at the same time avoided, has been, therefore, the great object of 
many of those who have had occasion to perform the operation. Mr. 
Spencer Wells, for example, in a case in which he performed it with a 
successful result, passed an uninterrupted silk suture, the end of which 
he brought through the vagina, and subsequently removed ; while Dr. 
Barnes suggests an ingenious but more complicated method, by which 
the uterus is stitched and united to the margin of the abdominal wound, 
while provision is, at the same time, made for the contraction above re- 
ferred to. But at the present day, we can scarcely doubt that, by many 
operators, the carbolized catgut sutures will be preferred. 

Whether or not the uterine wound is stitched, that in the abdominal 
wall is, of course, to be carefully closed by suture. The material to 
which a preference is usually given is fine silver wire, of which five or 
six stitches are to be passed through the cutaneous and peritoneal margins 
of the incision ; and after these have been carefully adjusted, they are 
to be drawn tight and fastened in the usual way, additional superficial 
sutures being, if necessary, added, so as to bring the whole length of the 
superficial incision into accurate apposition. The carbolized catgut sug- 
gested by Professor Lister may be substituted, in part at least, for the 
silver wire, and prepared gauze or other antiseptic dressings may now be 
applied. 

A full opiate should now be administered either by enema or supposi- 
tory, and perfect quiet and rest enjoined, the dressings being undisturbed 
for five or six days. The sutures are to be removed about the eighth 
day. The vagina may be washed out by injections of weak carbolic 
solution, and the bladder emptied by means of the catheter twice a day ; 
and, on the fourth or fifth day, the bowels may be relieved by a simple 
enema. The diet throughout should be of the lightest possible character, 
and every conceivable disturbing element, bodily or mental, should be 
scrupulously avoided. 

Reference has already been made to the operation of ovariotomy. It 
must not, however, be supposed that we have any idea of tracing the 
analogy which exists betw^een the two operations. Hysterotomy, in- 
deed, involves conditions which are manifestly far less favorable than 
those which attend on an ordinary case of ovariotomy, and we need not 
wonder that the results are less successful. We cannot, however, avoid 
the reflection, that not many years ago the latter operation was looked 
upon as scarcely more promising in its results than that which we are now 
considering ; and, when w^e reflect further upon the wonderful improve- 



536 ' HYSTEROTOMY. 

ments which modern surgical skill has effected in the one operation, we 
are surely justified in expressing a hope that the experience thus gained 
may be so made available as materially to reduce, in the future, the 
fearful mortality which, in the past, has attended the Caesarean Section. 
Upon nothing will the result be more likely to depend than upon the 
period at which the operation is performed. If, as has too generally 
been the case in this country, it is adopted only as a last resource, when 
the vital powers are exhausted by lingering labor, the expedient is, in- 
deed, a desperate one. But if, on the contrary, the necessity is recog- 
nized at a period sufficiently early to enable us to select the time and 
the conditions which are most favorable, our prognosis will admit of some- 
thing more of hope. 

The shock of the operation is often very great, and may prove fatal 
at once, before the secondary effects of peritoneal inflammation have 
manifested themselves. Hemorrhage is, as we have said, and as the 
experience of Winckel has shown, by no means a prominent cause of the 
fatal result; but it is otherwise with peritonitis, which may be looked 
upon as almost inevitable when the woman survives the immediate effects 
of the operation. This may come on within twenty-four hours, and is 
indicated by the occurrence of rigor, severe abdominal pain, with more 
or less tenderness on pressure, labored respiration, flatulent distension of 
the bowels, and a rapid, wiry pulse. These alarming symptoms may be 
combated by fomentations or poultices to the abdomen, mild salines, and 
opium; but, unfortunately, in the great majority of cases, the symptoms 
will go on unchecked until, under their influence, the patient succumbs. 
Metz, of Aix-la-Chapelle, insists upon the importance of the sustained 
use of cold in averting peritoneal inflammation. The rash employment 
of this agent would, undoubtedly, as every one knows, rather tend, by 
reaction, to produce inflammation than to repress it ; but of this Metz 
was quite aware. He recommends that, so soon as the woman has been 
put to bed after the operation, compresses of cold water should be placed 
over the abdomen, and that, after a few hours, ice in a bladder should be 
substituted, while cold injections are thrown into the rectum, and the 
patient is encouraged to" swallow, from time to time, morsels of ice. 
Under such treatment, he says, the patient is sensible of a feeling of 
comfort to Avhich she was previously a stranger, and this sensation may 
be fully trusted to as a safe guide to the length of time, and the extent 
to which this mode of treatment may be safely carried. So long, then, 
as the woman remains comfortable, cold may be employed; but the 
moment she complains of chill or discomfort, the cold is at once to be 
modified or withdrawn. Cazeaux seems to give a general support to this 
mode of treatment, which has also been practised by Kilian. Dr. Metz 
asserts, that of thirteen cases treated on this principle one only died — a 
statement so glaringly absurd, that we can only suppose this is one of 
the many pernicious instances of the reckless use of statistics with which, 
unfortunately, the literature of obstetrics is disfigured, and which some- 
times makes us incline to pass by with contempt suggestions which may, 
nevertheless, have in them the germ of truth and practical worth. 

It sometimes happens, as a result of the healing process, that the 
uterine and abdominal wounds become agglutinated, so as to produce 



GASTROTOMY. 537 

permanent adhesion at this place, without, as would appear, entailing any 
serious inconvenience. This fact is made use of by those who advocate 
the stitching together of the two wounds, and there has been proved to 
exist, in some of those cases in which the Cae^arean Section has been re- 
peatedly performed, an extent of adhesion which has admitted of the per- 
formance of the operation without opening the peritoneal cavity ; and it 
is obviously to this fact that the exceptional success attendant on such 
operations is to be attributed. 

G-astrotomy is an operation which has already been alluded to as 
applicable to cases in which the child has escaped into the abdominal 
cavity, either from a ruptured uterus, or in cases of extra-uterine preg- 
nancy. Some of the older cases which hav^e been recorded as Ci^sarean 
Section have clearly been of this nature — the operation being, as is 
obvious, only one stage of the more formidable procedure which we have 
been considering. There may, possibly, be cases, moreover, as has 
already been shown, in which, although the cyst of an extra-uterine con- 
ception has not been ruptured, it is necessary to perform this operation 
when the life of the mother is threatened by pressure on important 
organs, and also under some other circumstances of a like nature. 

The operation is simply the first stage of the Ci^sarean Section, and it 
is to be conducted with precisely the same precautions ; but an aperture 
must be left at the lower part of the external wound, to permit of the 
escape of the discharges by a drainage-tube or otherwise. It might 
naturally be inferred that an operation, which does not involve the 
uterine Avails, would be attended with much more favorable results. In 
practice, however, we shall probably, when we take the whole circum- 
stances into consideration, look upon the one with as great apprehension 
as the other. The operation of Gastrotomy has, in fact, certain special 
dangers in the practice of midwifery, and is very different, in all respects, 
from the ordinary operation for the removal of an ovarian cyst. The 
conditions which attend rupture of the uterus, or of an extra-uterine cyst, 
have already been detailed, when those accidents were under considera- 
tion. In each case, the ovum, its appendages, and the liquor in which it 
floats, all escape into the peritoneal cavity, along with a large quantity 
of fluid and clotted blood — a portion of which must necessarily be left 
behind — so that the chances of peritonitis are probably not less in the one 
case than in the other. And, in the case of extra-uterine pregnancy, the 
peculiar anatomical conditions which are often involved in the nature of 
the placental attachment, are of such a nature as to render these cases 
specially hazardous. In fact, whatever statistics may seem to prove, 
and Kilian and a few others may have said, we must always look upon 
this operation as one of the last resources of our art. When the incision 
is made in the lateral region, the operation is termed Laparotomy . 

When the child is extracted by means of incision, practised from the 
vagina, the operation has by some been termed Vaginal Csesarean Sec- 
tion, a phrase which is obviously improper. The circumstances which 
may render necessary such an operation as this, are malignant disease of 
the OS and cervix, congenital occlusion of the os, or retroversion of a 
gravid uterus. Similar operations, not involving the tissues of the uterus, 
may be practised in some rare instances of extra-uterine pregnancy, in 



538 SYMPHYSIOTOMY. 

which the foetus may be reached in this way ; but, in all these cases, the 
operation is simple, and requires no special directions other than to use 
bistouries and other instruments so guarded as to incur no risk of wound- 
ing the surrounding tissues ; and, at the same time, to cut with care, so 
as to avoid inflicting any injury upon the child. 

Symphysiotomy. — In 1768, Sigault, a young student of medicine, at 
Paris, submitted to the Academic de Chirurgie a proposition that women 
might be delivered without very great risk, by means of an operation 
which he thus named. The proposal was received with ridicule, and the 
essayist was treated as a madman. Nothing daunted, however, by this 
rebuff, the young Sigault stoutly maintained his position for several 
years, but it was not till 17T7 that he performed his first operation in 
the presence, and with the assistance of the celebrated Leroy, who, 
having espoused his cause, ultimately became a warm advocate of the 
new procedure. Both mother and child were saved in this case, and 
Sigault soon found himself famous and overwhelmed with benefits, as the 
discoverer of a method which was to replace the hated Csesarean Section, 
and, consequently, as a benefactor of his race. The Academic de Mede- 
cine, as if to atone for the indignity which the sister society had put 
upon him, received him with open arms, and actually struck a medal in 
honor of the event. In France and Germany the profession was much 
divided on the subject, but in England it somehow never gained a foot- 
ing, nor would we even now have given any attention to the matter, were 
it not that, in all modern Continental Avorks on obstetrics, some degree of 
prominence is still given to the operation, as one which might, under cer- 
tain circumstances, be advantageously performed. 

The division of the pubic symphysis is, from a surgical point of view, 
a matter so simple, that it is unnecessary to particularize the details. It 
is proper, however, that in expressing as we now do the opinion that the 
operation is one which must be unhesitatingly and absolutely rejected as 
irrational, some reason should be adduced for a view which is so confi- 
dently expressed. To begin, then, symphysiotomy is to be rejected as a 
mere chimerical idea, which had its origin in views as to the movement 
of the pelvic bones during labor, than which nothing, theoretically or 
practically, could be more incorrect. It was shown, in an early chapter 
of this work, that the very trifling movement which nature permits during 
labor in the human pelvis is one in which the symphysis pubis is the 
hinge. At the time when Sigault wrote, the idea usually entertained 
was exactly the opposite — viz., that the hinge was at the sacro-iliac syn- 
chondrosis, and that the pelvis gaped at the symphysis ; and it could 
only, of course, have been with the object of encouraging such a move- 
ment as this, that the operation could on rational grounds be supported. 
Again, such an obstruction as might seem to call either for Craniotomy, 
the Csesarean Section, or this new operation, would, in a considerable 
majority of all cases, consist mainly in contraction of the conjugate 
diameter of the brim ; but a moment's reflection will serve to show that 
this operation is not one which is likely to increase the diameter thus 
encroached upon, for, Avhile it certainly will augment the circumferential 
measurement of the pelvis, and the transverse and oblique diameters, it 
leaves the conjugate comparatively untouched. And, if we turn to the 



GASTRO-ELYTROTOMY. 539 

results of the operation, we will at once find that the boasted advantage 
has no existence, save in the imagination of the inventor. Baudelocque 
says that, in forty-one cases of the operation, fourteen women died, while 
only thirteen children were born alive. The narrative of recorded cases 
shows that, while the forces of nature may prevail after the operation, it 
will often be found necessary to apply the forceps, or turn, after the 
original operation has been completed. As regards ultimate results, 
Cazeaux says, " In the most fortunate cases, the consolidation of the 
symphysis is only complete after a lapse of three or four months. 
Women have been seen in whom it had never taken place, and who, 
nevertheless, have eventually been able to walk. There then forms, 
according to Alphonse Leroy, a fibro-cellular tissue which, filling up the 
gap in the symphysis, maintains the solidity of the articulation." 

Various modifications of the operation have been suggested, including 
one method which has received the support of Stoltz of Strassburg, and 
which he termed Puhiotomy. In this case the operation is performed 
by a chain saw, which is introduced subcutaneously. A small opening 
is first made to the right or left of the middle line over the pelvic crest, 
and through this a strong needle, slightly curved, is introduced. This is 
passed behind the pubis, and brought out by the side of the clitoris, and 
by it the chain saw, to which it has previously been attached, is pulled 
through, and made to act upon the body of the pubis from within out- 
wards, until the bone has been divided. The operation of symphysiotomy 
has been but once practised, in so far as we are aware, in this country; 
and on the Continent, in the present day, it is so seldom employed that 
the question may now be looked upon as forming little more than an 
episode in the history of the operative midwifery of the past. 

The operation of G-astro-Elytrotomy or Laparo-Elytrotomy , which 
was originally suggested some sixty years ago, has quite recently 
attracted great attention as a possible substitute for hysterotomy, and 
several successful cases have been reported in America by Professor 
Thomas of IN'ew York, and Dr. Skene of Brooklyn.^ In this country it 
has been twice performed, in both instances unsuccessfully. The main 
object of the operation is to avoid opening the cavity of the peritoneum, 
while at the same time the necessity of incising the uterine tissue is ob- 
viated. To efi'ect this, an incision is made in the line of the groove from 
the symphysis pubis to the anterior superior spinous process of the ilium. 
After the superficial structures have been divided and the peritoneum 
exposed, the latter is carefully raised from its feeble attachments until 
the vagina is reached and opened. The bladder must be previously 
emptied, and carefully kept out of the way by a sound, during the ope- 
ration, as experience has shown that injury to that viscus is one of the 
special dangers of the operation. The os and cervix — already consider- 
ably dilated either by operation or by natural labor pains — are then 
hooked into the wound, and the operator, introducing his hand, delivers 
by turning, the child being extracted through the wound in the abdom- 
inal parietes. No special surgical difficulties seem to attend the opera- 
tion, and it is clear that theoretically much may be said in favor of it. 

1 See American Journal of Obstetrics, vols. iii. and x. 



510 GASTRO-ELYTROTOMY. 

But before definitely pronouncing an opinion with reference to Gastro- 
Eljtrotomy as compared with the Caesarean Section, it would be neces- 
sary to await the results of a somewhat wider experience ; but there are 
certainly, in the present state of the matter, no valid grounds to debar us 
from anticipating in this a possibly important addition to the operative 
resources of our art. 

It may be interesting at this place, by way of recapitulation — but 
without any pretence of, or attempt at, anything more than an approxi- 
mation at accuracy — ^to set down, in a tabular form, the various conju- 
gate measurements at the brim which, according to the best authorities, 
may be supposed to indicate the necessity for the several operations 
which we have now been considering. Burns, speaking of one of the 
operations referred to, says, — and the observation will apply with equal 
force to any of them, — " There is only one degree of disproportion, 
then, betwixt the head and the pelvis which will admit of this ; but the 
smallest deviation from it destroys the advantage of the operation. Now, 
as this disproportion is so nice, we cannot in practice ascertain it ; for, 
although we could determine, within a hundredth part of an inch, the 
capacity of the pelvis, yet we cannot determine the precise dimensions of 
the head, and thus establish the relation of the two." The student, we 
w^ould again repeat, — at the risk of being accused of unnecessary itera- 
tion, — must, above all things, beware of assuming that conjugate con- 
traction is his only guide, or one which is uniformly to be relied upon. 
The following figures, therefore, have reference only to cases of conju- 
gate contraction, in which the other diameters are either unaltered, or 
are, at least, not very greatly diminished. With reference, more par- 
ticularly, to the Csesarean Section, in which osteomalacia is the most 
frequent cause of deformity, it should be remembered that, in that type 
of pelvis, the conjugate measurement, so far from being a criterion of the 
deformity, is more likely to lead the observer to conclusions which are 
quite erroneous. 

With this explanation, then, the following may be given, as showing, 
according to the most approved authorities, the degree of conjugate con- 
traction at the brim, which may be supposed, under ordinary circum- 
stances, to indicate the various operations which have been described : — 

Long Forceps ....... 4 

Turning 3^ to 2f 

Craniotomy . . . . . . . 3 to 1^ 

Csesarean Section, or Gastro-Elytrotomy . . 1^ and under. 



INDUCTION OF PREMATURE LABOR. 541 



CHAPTEE XXXIY. 

IXDUCTIOX OF PREMATURE LABOR. 

History of the Suhject. — Nature and Scope of ilie Operation. — Viahilitij or Xon- 
Viahility of the Child. — Conditions ichich justify the Operation, — Various 
Methods of Provolcing Uterine Action: Ergot: Puncturing the Membranes : 
Separation of the Membranes by Hamilton's Method: Dilatation of the Cervix 
by Tents: Introduction of an Elastic Bougie or Catheter into the Uterus: 
Plugging or Distending the Vagina: The Method of Kiivisch by the Vaginal 
Douche: Cohen's Method by Intra- Uterine Injections: Dr. Barnes' Process, 
consisting of a ^'■Provocative" and an '•'■ Accelerative" Stage: Galvanism: 
Irritation of the Breasts. — Anatomical and Physiological Fitness of the Parts. 
— Constitutional Influences. 

It is with something of a sense of relief that we turn from a con- 
sideration of the destructive operations of midwifery, to what is perhaps, 
in the strictest and truest sense, the most conservative of all the resources 
of our art. There is a fitness, moreover, in considering the subject at 
this place, as it aflfords, within certain limits, a means by which the neces- 
sity for the more serious operations may be avoided. 

Of all methods of operative procedure which are applicable to the 
practice of obstetrics, there is none which has given rise to such pro- 
longed and often acrimonious discussion. Putting aside various expe- 
dients which were occasionally adopted both in ancient and modern times 
to expedite delivery, there can be no doubt that the induction of prema- 
ture labor is an operation which we owe to the sound judgment of the 
English school of midwifery, by the sheer force of which, and the vigor- 
ous support it received from many influential quarters, the operation was 
soon forced into notice. In 1756, a conference was held in London, 
which was attended by the most eminent practitioners of the day, at 
which this question was fully and exhaustively considered in all its 
bearings, with the result of formally admitting it as a recognized practice 
of the English School. 

For reasons which have already been more than once adverted to, the 
induction of premature labor was not likely to obtain a ready assent on 
the Continent, where, on the contrary, it found opponents who were so 
virulent in their hostility, that an operation, which is perhaps above all 
others morally right, as well as beneficent in its action, was for many 
long years contemptuously rejected. The great force of truth, however, 
ultimately prevailed, and the operation was performed in Germany by 
\Yenzel in 1804; but it was not till 18B1 that Stoltz of Strassburg led 
the way by performing the first operation in France — not the least of the 
benefits which this distinguished obstetrician conferred upon that branch 



542 INDUCTION 0¥ PREMATURE LABOR. 

of science with which his name is honorably connected. From this mo- 
ment, the success of the operation was assured, even in the country 
where it had been longest resisted. Sentimental scruples in regard to 
foetal life, which had swayed the opinion of many, w^ere shown to be in 
this case quite irrational, and could be supported by no argument, moral 
or religious, the sophistry of which could not easily be exposed. As 
time wore on, all doubt vanished, and it may now be said that in the pre- 
sent day, the practice on the Continent is as advanced as it is in England, 
and perhaps of late years the operation has attracted even more attention 
than with us. The only remnant of the original prejudice, which still 
exists in the minds of some, is the opinion, occasionally entertained, that 
we should not perform the operation repeatedly upon the same woman, 
on the principle which has induced these persons to bring the interests of 
the child into greater prominence in the case of a woman who has once 
been delivered by craniotomy, and who ought, therefore, according to 
them, to be exposed to the fearful danger of the Csesarean Section, in 
order that the infant may be born alive. 

The induction of Premature Labor, in its widest sense, is an operation 
varying greatly in its details, whereby the uterus is artificially stimu- 
lated to expel its contents at any period prior to the completion of the 
full term of utero-gestation. The micrest glance at the subject will 
therefore suffice to show that the operator must feel the sense of respon- 
sibility more, the earlier the period of pregnancy at which the presumed 
necessity for the operation may arise. At the sixth, and at the ninth 
month, the operation will diifer in no essential particular, and may be 
attended with equally trifling risk to the mother. But, in the one case, 
we sacrifice a child, by bringing it into the world before it is viable ; 
while, in the other, we merely induce the premature expulsion of an in- 
fant which there is every reason to suppose may survive ; so that, we 
must carefully draw a distinction between the induction of abortion^ and 
of premature labor in its more restricted sense. The general opinion, 
which has found expression in the "Code Napoleon," is, that the end of 
the sixth month is the period at which the foetus may be considered via- 
ble ; but the experience of all accoucheurs extends this till about the 
twenty-ninth week, — before which time, indeed, we have but little hope 
that the child may be reared. It is clear, therefore, that if the cause 
calling for the induction of premature labor is of such a nature as to 
warrant us in deferring the operation until the end of the seventh month 
has been reached, we should do so, avoiding, at the same time, the risk 
of over-caution, which by delaying too long, may leave the mother ex- 
posed to the dangers from w^iich it is our primary object to save her. 

The conditions under which we may be justified in performing the 
operation vary considerably. When we operate before the middle of 
the seventh month, we may look upon our procedure as one which we 
■undertake in the interests of the mother alone, without any reference to 
the child, which is thus deliberately sacrificed. While it is true that 
these are the cases in which a sense of responsibility is most likely to 
weigh upon us, there are instances, undoubtedly, in which delay incurs 
a responsibility more serious still, in leaving the case to nature, when the 
sole alternative of the Caesarean Section will almost surely result in the 



CONDITIONS WHICH JUSTIFY THE OPERATION. 543 

sacrifice of the mother, and probably also of the child. There is another 
class of cases, — which have been alluded to in a previous chapter, — in 
which we are sometimes, though very rarely, warranted in inducing 
abortion. The most familiar example of this is found in the excessive 
vomiting which occasionally attends pregnancy, so as to bring women 
previously healthy to the very verge of dissolution. We have great dif- 
ficulty in admitting this as a cause justifying abortion, and most cer- 
tainly no young practitioner should have recourse to the operation, without 
very careful consideration, and, if possible, the advice and assistance of 
those more experienced than himself. For, if disaster does occur, — and 
we cannot doubt, from cases given by Tyler Smith and others, that it 
occasionally does so, — from delay, we cannot but fear that a too great 
familiarity, under such circumstances, with an operation which is in 
itself simple enough, would result in a wanton sacrifice of foetal life. 
Nature, as we have already shown, almost invariably comes to the relief 
of such cases, so that the circumstances which might warrant the opera- 
tion must be extremely rare. 

There are instances again, in which, at a more advanced period of 
pregnancy, the operation is undertaken in the interests of the child. 
There are few practitioners of much experience, who have not encoun- 
tered cases in which women, often apparently robust, have been, on suc- 
cessive occasions, delivered of still-born children near the full time. In 
such, we should not hesitate to bring on labor before the time at which 
the death of the foetus was presumed to have occurred in former preg- 
nancies, fixing the period as near the natural termination of the preg- 
nancy as may be deemed prudent. The causes which give rise to the 
death of the foetus, in these cases, are often obscure, and sometimes can 
by no means be distinguished ; but in most instances there is, as we may 
assume from what has actually been demonstrated, some diseased condi- 
tion, Avhich interrupts the placental circulation, and thus causes the death 
of the child. Any of the diseased conditions of the placenta formerly 
enumerated, — such, for example, as fatty degeneration, — may have this 
effect ; and it is, probably, when the disease is rapidly progressive, 
towards the end of pregnancy, that we are able, by premature delivery, 
to avert its otherwise inevitable effect on the life of the child, by placing 
the latter in circumstances in which, aerial respiration having been estab- 
lished, it is independent of the placental circulation. 

It is, as we have seen, a natural physiological accompaniment of preg- 
nancy, towards its termination, that the utero-placental tissues loosen 
somewhat, preparatory to the occurrence of delivery; and, when no 
actual disease of the placenta can be discovered, it has been supposed 
that premature separation of the decidua may, either by rupture of. the 
vessels, or by interference with the circulation Avithin them, directly or 
indirectly destroy the foetus. In some cases, — of which we have seen 
two examples, — it would seem as if the uterus, as in habitual abortion 
independent of disease, had assumed a habit of throwing ofi*its contents 
at a certain time, before the conditions otherwise favorable to live birth 
were in operation ; and yet, when this so-called habit is once broken by 
the induction of premature labor at a somewhat earlier period, the woman, 
in subsequent pregnancies, carries her children to the full time. The 



544 INDUCTION OF PREMATURE LABOR. 

operation may even be warranted in cases in which, although the children 
may have previously been born alive, they have, owing to the occurrence 
of some of the diseases referred to, been the subjects of what has been 
termed, with some propriety, " intra-uterine marasmus," and have not 
long survived their birth. In cases of still-birth, a very excellent rule 
which has been laid down for our guidance in subsequent pregnancies is 
to examine with great care the placenta and membranes. 

The cases which are most frequent in their occurrence, and, at the 
same time, most satisfactory in their results, are those in which we ope- 
rate with the double object of saving both mother and child from great 
peril or almost certain death. Merriman has insisted, with great justice, 
upon the caution which we should exercise, when the conditions w^hich 
seem to indicate the necessity for premature delivery occur inprimiparag. 
To a great extent, this warning is sound and judicious, but we must avoid 
carrying the principle too far ; for, if the circumstances are such as seem 
to preclude the possibility of the passage of a mature foetus at the full 
term, we are equally justified, in primiparae, as in other cases, in having 
recourse to an operation which thus obviates an otherwise inevitable 
risk. In pluriparse, much, and possibly everything, will depend upon 
the history of former labors. If, for example, it has been found neces- 
sary, once or oftener, to relieve the woman in previous labors by the 
operation of craniotomy, or even by turning or the long forceps, with an 
invariably fatal result as regards the child, the estimate which we may 
be inclined to form of the probable danger is thus corroborated by expe- 
rience ; but, where the indications are less certain, we must be thoroughly 
convinced that the operation gives the best chance to the child as well 
as to the mother, before we can hold ourselves as warranted in acting. 

Inasmuch as the life of the infant will depend, in all cases, upon the 
degree of development which has been attained prior to birth, it is of the 
first importance that we should form a correct estimate of the period be- 
yond which we cannot safely go. As the necessity for this proceeding, 
as well as for the more serious expedients of embryotomy and the Csesa- 
rean Section, arises, in a very large proportion of cases, from contrac- 
tion of the conjugate diameter of the brim, we should, in the first place, 
endeavor to ascertain, with as much accuracy as may be attainable, the 
precise degree of the contraction. This may be done approximately by 
the methods of pelvimetry which have been already detailed. It is ob- 
vious that such an amount of contraction as would call for the Caesarean 
operation, will require measures for the relief of the woman to be taken 
at an earlier period than when the diameters are such as to point to em- 
bryotomy. In cases of conjugate contraction, as has already been shown, 
the head lies pretty nearly in the transverse diameter, so that it is the 
bi-parietal measurement which corresponds to the contracted diameter of 
the brim. 

While estimating, therefore, the degree of pelvic contraction, it is pro- 
per that we, at the same time, bear in mind the probable measurements 
of the bi-parietal diameter of the cranium at various epochs in the course 
of the last two or three months of pregnancy. Stoltz has ventured to 
give measurements which, reduced to the standard of the English inch, 
we may quote as probably approximating the actual condition of the parts. 



CONDITIONS WHICH JUSTIIY THE OPERATION. 545 

Between the thirty-second and the thirty-third week, the bi-parietal diam- 
eter is somewhere about two inches and three-quarters ; from the thirty- 
fourth to thirty-fifth, three inches ; and from the thirty-sixth to the thirty- 
seventh, three inches and one-third. If, therefore, we have to deal with 
a case in which the conjugate diameter is two inches and a half, or under, 
we should operate not later than the end of the seventh month, even 
making all allowance for the greater compressibility of which the head, 
at this early period, is susceptible. Conclusive proof of twin pregnancy 
may, as Cazeaux has shown, modify our procedure in this particular, or 
might even warrant us in abandoning the case to nature, if the contrac- 
tion is not excessive ; and this for two reasons, — because twins are gene- 
rally less developed, and because their organization is seldom so perfect 
when they are prematurely born as to enable them to maintain an inde- 
pendent existence. 

In cases of pelvic distortion where the conjugate falls under one inch 
and three-quarters, the only possible alternative will, in most cases, be 
the Csesarean Section. A case such as this necessitates abortion, for it 
is only by operating in the course of the sixth month at latest, that we 
can expect to save our patient, by the expulsion of the foetus before the 
period of viability. At whatever period the operation may be resolved 
upon, there is always a greater probability, which should not be lost sight 
of, of obstruction from malposition of the foetus ; and the more removed 
the case is from the natural term of gestation, the more likely is this to 
occur, and to constitute a practical difficulty which may not have been 
anticipated. It must not be supposed that pelvic contractions are the 
sole conditions, in addition to such as have previously been mentioned, 
which lead to the operation we are now considering. We have already 
seen that, in certain cases of hemorrhage, whether accidental or unavoid- 
ble, the only course of procedure that we can adopt is one which, by in- 
citing the uterus to premature contraction, relieves the mother from the 
state of peril into which she has fallen, and, at the same time, may be 
the means of preserving the child. 

But, in addition to these, which clearly point to the operation, there 
are many other instances which may fairly be admitted to stand in a more 
doubtful category. When a woman, for example, is towards the end of 
pregnancy affected by a serious disorder, which apparently places her 
life in immediate jeopardy, it cannot fail to be a matter of anxious con- 
sideration whether or not we are to reject the operative means which we 
have at our command, which will generally save the child, and may often 
save the mother. Here, as in all other cases, we must place the interests 
of the mother before those of the child. It will not be a safe rule in 
practice, although it may seem so in theory, that we may operate to save 
the child, if we are persuaded that, by so doing, we shall not augment 
the danger of the mother ; so that we should, in such cases, operate only 
when we can convince ourselves that the procedure is also, in the main, 
one which affords the mother the best chance of her life. 

Cases of this kind, under a variety of forms, occasionally occur in 

practice. In dropsical eff"usions into the great cavities, to such an extent 

as to interfere seriously with the function of respiration, no profound 

consideration is required to show that distension of the uterus is an ele- 

35 



546 INDUCTION OF PREMATURE LABOR. 

ment or unit in the mechanical causes which place the woman's life in 
peril ; and it is, at least, a reasonable assumption that, by subtracting 
this unit from the sum total of unfavorable conditions, we give the mother 
an additional chance, while we withdraw the child from the operation of 
causes which may materially imperil its existence. Certain cases of 
cardiac disease, or of aneurismal tumors, in which the pressure of the 
gravid uterus seems likely to precipitate a catastrophe which we may 
regard as ultimately inevitable, may, on similar principles, be our warrant 
in inducing a premature expulsion of the uterine contents ; but, in the 
course of practice, other exigencies may offer themselves, in which, while 
the indications are less clear, we may yet consider ourselves justified in 
bringing the pregnancy to an abrupt termination. 

Several years ago, we had an opportunity of seeing a case of this 
kind in consultation with Dr. Dobbie of Ayr. The patient was a lady 
aged thirty, wdio had been for some years the subject of chronic asthma. 
She was, in the eighth month of her fourth pregnancy, laboring under 
severe chronic bronchitis, of a cyanotic appearance, and with an extremely 
feeble and irregular pulse. All the ordinary means, applied with much 
skill and discrimination, had failed to afford any relief, and it was, there- 
fore, resolved, in the apparently desperate circumstances of the case, to 
have recourse to the induction of premature labor. Dr. Dobbie kindly 
supplied me afterwards with the following details of the issue of the 
case : "About eight o'clock on Friday evening I made a vaginal exami- 
nation, with a view to learn the exact position of things, and, in doing so, 
I found the tissues all so lax and moist, and the uterus reaching so low 
in the pelvis — almost touching the perineum — that, without withdrawing 
my hand, I commenced dilating the os, first with my forefinger, and then 
with the fore and middle fingers. At the end of half an hour, and 
without any complaint of pain on the patient's part, the os was fully the 
size of a crown, and I left it. Pains had slightly commenced by this 
time, and they went on increasing, but, throughout the labor, they were 
of a very moderate kind. At 10.45 P. M. labor was terminated by the 
birth of a living and healthy female child. We did our best to support 
strength by stimulating freely; but without avail. She died at 5 A. M. 
on Saturday." 

This is a tolerably good illustration of the exceptional cases referred 
to. The result, as regards the mother, was only what might have been 
anticipated, had the symptoms detailed been observed unconnected with 
the pregnant state ; and, if the case had been abandoned to the operation 
of nature, we cannot doubt that the result would have been a dead child 
as well as a dead mother. Furthermore, a retrospect of the case does 
not now modify, in any degree, the opinion which we entertained from 
the first, that the course resolved upon was — putting the child entirely 
out of consideration — that which gave the patient the benefit of the last 
ray of hope which remained for her. It is impossible to detail all the 
conditions which may be supposed to justify a similar course, but we may 
mention dropsy of the amnion, fibrous or other tumors, albuminuria, con- 
vulsions, and mania, as among the circumstances which have, in the ex- 
perience of able practitioners, been found to call for the operation. 



THE OPERATION. 547 

Tlie Operation. — k^ usually practised, the induction of premature 
labor is a process in which operative aid plays an important, though a 
quite subordinate part. The accouclieme^it forcee of the older French 
writers was a mode of procedure very different from this ; and, although 
the opponents of the English scheme did not scruple so to designate it in 
their bitter hostility, no analogy between the two can, in any sense, be 
admitted. Various as are the methods which have been practised with 
a view to the expulsion of the foetus, these, with scarcely an exception, 
consist, in so far as operative procedure is concerned, of expedients which 
are adopted with the view simply of inducing the uterus to expel its 
contents. These prov^ocative measures are, as we shall see, very various; 
but, so soon as uterine action has once been thoroughly excited, the further 
progress of the case is usually left to nature. The different modes of 
inducing uterine contraction, which are here referred to, were divided 
by Stoltz into two classes. The first of these embraces all methods 
which are supposed to act primarily upon the system, with the object of 
producing, secondarily, the effect which we desire : the second compre- 
hends all proceedings which may be adopted, with the view of operating 
directly upon the ovum or uterus, and thus stimulating, by reflex action, 
the latter to contract. 

The operation of such means as may be referred to the first class is 
too uncertain, and is, in fact, so little to be depended upon, that, in 
modern times, they have been entirely abandoned, especially in cases in 
which delay is to be avoided ; and there are, probably, no accoucheurs 
of the present day who would waste time in maintaining an expectant 
attitude, in the hope that baths, bleeding, emetics, or even purgatives, 
might possibly produce what they desire. The only agent which, acting 
through the medium of the circulation, has still some supporters, is the 
ergot of rye. That this drug acts, in a large number of instances, upon 
the spinal cord, so as to influence the fibres of the uterus, is a fact which 
no one can gainsay ; but, in cases of abortion, and in all cases in which 
the uterus is in a state of i|uiescence, its action is more variable, and 
less to be depended upon, than when it is employed during labor. While 
we reject it, therefore, as a provocative agent, there seems no good 
reason why we may not use it in many cases — as we would in labor at 
the full time — to expedite delivery, or to sustain flagging uterine effort. 

The other plan, — that of operating upon the ovum or uterus, so as 
directly to excite the contraction of the latter, has entirely superseded 
such of the more remote and indirect modes of procedure as have by some 
been practised. AVe purpose to direct attention here to the more im- 
portant only of the numerous methods which have been devised directly 
to effect uterine contraction. 

1. The original mode of procedure, which received the support of the 
London Congress above alluded to, consists in the Rupture of the Mem- 
branes, by means of a quill sharpened at the point, or in any other way 
which may be considered more safe, in order to permit of the escape of 
the liquor amnii, and the partial collapse of the uterus. This is a very 
certain and effectual method of inducing premature labor, but it was soon 
found to be open to serious objections. In the first place, it compromises 
very decidedly the chances of the child, by allowing the uterine walls to 



548 INDUCTION OF PREMATUEE LABOR. 

come in contact with, and injuriously press upon it, in its imperfectly 
developed condition, from the beginning to the end of labor. And, sec- 
ondly, it is far from being free from danger, especially in cases of abor- 
tion, when, owing to the imperfect dilatation of the cervix, the membranes 
are difficult to reach ; and many cases have occurred of serious and even 
fatal results, from injuries inflicted upon the cervical tissues in the course 
of those eiforts, as has often been the case in recorded examples of crimi- 
nal abortion. On these grounds, with the exception of certain cases of 
hemorrhage and convulsions, in which, for special reasons, it is preferred 
to other methods, its use is to be condemned. 

2. Separation of the Membranes, by means of the finger or sound in- 
troduced through the os uteri, was recommended and practised by Profes- 
sor Hamilton, of Edinburgh ; but it may fairly be assumed that the result 
in such cases is due as much to the irritation and forcible dilatation of the 
OS and cervix, as to the partial separation of the membranes, which is 
eflected by sweeping the finger or sound round the lower segment of the 
uterus, so as to cause their detachment. Still, as the integrity of the 
membranes is in this way preserved, although, in many cases it must 
necessarily be imperilled, this may be looked upon as an improvement 
upon the original process. 

3. The Dilatation of the Os by tents has also been practised with con- 
siderable success, but in this case something more is attempted than a 
mere excitement to contraction, in the forcible dilatation of the parts, by 
which the natural process is in some degree aided. This latter indica- 
tion is, however, more thoroughly carried out in the m&thod suggested by 
Dr. Barnes, as will afterwards be more particularly explained. 

4. The process which, in the opinion of most operators of the present 
day, is to be preferred, as combining, in the highest degree, the qualities 
of safety and efficiency, is the introduction within the uterus and outside 
of the membranes, of an Elastic Catheter, which is passed without a 
stylet for six or seven inches, and is allowed to remain in position. The 
presence of this is resented by the uterus, and, sooner or later, the organ 
is stimulated to contraction, as by any other foreign body. The risk of 
injuring or separating the placenta, which some have urged as an objec- 
tion to this process, may practically be dismissed. With a stylet, that 
might possibly occur ; but, when the catheter is introduced properly, the 
resistance of the placental adhesion would, if encountered, be sufficient 
to turn aside the flexible stem. 

5. The introduction of Foreign Bodies into the Vagina has been trusted 
to by some as a means of inducing premature labor. It has already been 
remarked, in discussing the treatment of the hemorrhage of abortion, that 
the great objection to the use of the plug was the danger, amounting 
almost to certainty, that the uterus would thereby be excited to expel its 
contents. As our object in the one case is to induce, what in the other 
we seek to avert, it may fairly be admitted that distension of the vagina, 
by Braun's Colpeurynter, Gariel's air pessary, or any other form of plug, 
is a safe method of provoking the uterus to contract, although tardy and 
uncertain in its action. 

6. The use of Vaginal or Uterine Injections was first suggested by 
Continental practitioners ; and, as both of these methods have received 



VAUIOUS METHODS. 549 

no inconsiderable amount of support in this country, it is proper that we 
should give to them some particular consideration. The method of Vagi- 
nal injection, which, is known on the Continent as that of Kiwisch, has, 
in this country, received the support of Tyler Smith, Churchill, and other 
eminent accoucheurs. The process, as originally suggested, consists in 
directing a continuous stream of warm water upon the os uteri by means 
of a long tube, which is connected with a vessel placed several feet above 
the level of the patient. Some operators, trusting to the eifect of the 
warmth of the injection, allow free egress of the fluid from the vagina, 
while others use measures to prevent its escape, with the view of effect- 
ing anatomical detachment of the membranes from the uterine wall ; and 
Tyler Smith expresses a preference for the alternate use of hot and cold 
water, as more certain to excite uterine action. The injection is to be 
repeated once or twice a day, for ten minutes or a quarter of an hour, 
when it seldom fails to bring on contraction after eight or ten applications, 
and sometimes after two or three. Dr. Simpson substituted an ordinary 
Higginson's syringe, and various modifications of the original apparatus 
have, from time to time, been suggested. Simple and safe as this method 
may appear, later experience has shown that it is by no means free from 
risk, and fatal cases have been reported in which death had occurred ; 
so that, if it should be employed, caution must in every case be exer- 
cised ; and we apprehend that it can only be adopted with perfect confi- 
dence, as regards the safety of the patient, when nothing is done to pre- 
vent the free escape of the fluid from the vagina. 

The intra-uterine douche, which is generally known as Cohen's method, 
was first recommended by Schweighauser in 1825. It was originally 
introduced as an improvement upon Hamilton's process, as, in its opera- 
tion, it more thoroughly and ett'ectually separates the membranes from 
their uterine attachments. Abundant proof has been afforded that this 
is an effective plan, but it remains for our consideration whether or not 
it is to be admitted as a safe one. Dr. Barnes has collected no less than 
ten cases in which a fatal result ensued from the employment of the 
intra uterine douche, in some from shock, in others, as has been assumed, 
from the passage of the injected fluid through the Fallopian tubes into 
the abdominal cavity, and in others, as in a case which he quotes from 
Ulrich, by the entrance of air into the circulation through the uterine 
sinuses. In two cases mentioned by Simpson, the cause of death was 
rupture of the uterus. " The occurrence," he says, " of the rupture was 
to be explained by the fact, that the uterus, being already fully dis- 
tended, could not admit the few ounces of fluid without being stretched 
and fissured to some extent ; and durinor labor these slio;ht fissures mio;ht 
easily be converted into fatal ruptures. In one case, the patient died 
before labor was completed ; in the other, in twelve hours after its 
termination." It has also been urged by the same authority, that 
the placenta may be detached by such injections ; and that the position 
may possibly be altered, so as to change a cranial into a transverse 
presentation. 

While we cannot wonder that the methods above described have re- 
ceived much support from influential quarters, we fear that such results 
as have been reported must be taken as a sufficient warrant for the abso- 



550 INDUCTION OF PREMATURE LABOR. 

lute condemnation of the syringe as a means of inducing labor. Some 
doubt may be admitted as to the original plan of Kiwisch ; but, when 
this is combined with forcible distension of the vagina, by preventing the 
escape of the injected fluid, which is tantamount to Cohen's method, we 
feel that no evidence of mere efficiency, nor accumulation of successful 
results, will warrant us in exposing a patient to such danger, while, un- 
doubtedly, safer means are at our command. Injections of carbonic acid 
gas, and of common air, within the cavity of the uterus have also been 
practised, but with such results as to deter any one from such expedients 
in all time coming. 

7. The most recent method of inducing premature labor, is that which 
was suggested by Dr. Barnes, of dilatation of the os and cervix by means 
of graduated fluid pressure. A similar mode of procedure had previously 
been attempted by Dr. Keillor and Mr. Jardine Murray : but it is to 
Dr. Barnes that we certainly owe the complete scheme of cervical dilata- 
tion. The plan originally propounded by Dr. Barnes commenced by 
forcible dilatation of the os uteri, and was one, therefore, to which the 
Erench opponents of the general scheme would have applied their favorite 
term accouchement forcee^ with the full weight of the contemptuous 
epithet ; and to the modified procedure which he now advocates the same 
term might still, in a qualified sense, be applied. 

His process now consists of two stages — provocative and accelerative. 
For the first of these, and for reasons similar to those which have been 
advanced in the preceding pages, he prefers the fourth of the methods 
which we have described. Overnight he passes an elastic bougie six or 
seven inches into the uterus, and coils up the remainder of the instru- 
ment in the vagina. Under favorable circumstances, some uterine action 
will have been set up by the following morning ; and, if not, it must 
still be left in situ for a time, until it is evident that the provocative 
action has been established. " Before rupturing the membranes," he 
says, " adapt a binder to the abdomen, and let this be tightened, so as 
to keep the head in close apposition to the cervix. This will often pre- 
vent the cord from being washed down by the rush of liquor aranii. 
Dilate the cervix by the medium or large bag, until it will admit three or 
four fingers. Then rupture the membranes, and, before all the liquor 
amnii has escaped, introduce the dilator again, and expand until the 
uterus is open for the passage of the child. If the presentation is 
natural, if there is room, and if there are pains, leave the rest to nature, 
watching the progress of the labor. If these conditions are not present, 
and one or other is very likely to be wanting, — proceed with accelera- 
tive methods, — that is, to the forceps or turning ; or, in cases where the 
passage of a live child is hopeless, to craniotomy. By pursuing this 
method, we may predicate, with great accuracy, the term of the labor. 
Twenty-four hours in all, — counting from the insertion of the bougie, — 
should see the completion of the labor. The personal attendance of the 
physician during two hours is generally enough. The mode of proceed- 
ing must vary according to the conditions of the case." Writing in 1862, 
he^says, '' It is just as feasible to make an appointment at any distance 
from home to carry out at one sitting the induction of labor, as it is to 
cut for the stone." 



Barnes's method, 



551 




Barnes's Uteriue Dilators. 



The fiddle-shaped bags referred to in the above extract are of the 
form shown in the accompanying illustration. They are so constructed 
as to be grasped in the middle or constricted part by the os and cervix, 
which prevents them from slipping upwards into 
the uterus, or downwards into the vagina. Their 
introduction is effected by means of the little cup- 
shaped pouch which is attached externally, into 
which the point of the uterine sound may be 
adapted, and from which it may subsequently be 
withdrawn. Being first emptied of air, and folded 
upon itself, the stopcock at the end of the tube 
being closed, it is passed in this shape through 
the cervix. The nozzle of a syringe, which has 
previously been filled with water, is now adapted 
to the tube, through which the fluid is cautiously 
injected. After moderate dilatation of the bag, 
the stopcock is again closed, and the syringe re- 
moved, when the bag will be found to be firmly 
fixed in its place. A little practice, as we have 
learned by experience, is necessary in the man- 
agement of this instrument, and especially of the 
stopcock ; but a close observation of the apparatus, 
and a few test-experiments before its introduction, 
will obviate any difficulty, and will at the same time serve to insure the 
efficiency of the bag. The process of subsequent dilatation should be 
gradual, and is effected by repeated injections, which, while increasing 
the size of the bag, exercises a pressure or dilating force upon the cervix, 
which is perfectly equable, and which is a pretty close imitation of the 
manner in which nature effects dilatation by means of the sac of the 
liquor amnii. It may be necessary to use successive bags, which pro- 
gressively increase in size ; or, in the absence of a sufficient assortment, 
two bags may be simultaneous!}'' introduced, and successively dilated, 
until the requisite amount of distension is attained. The only objection 
which occurs to us, as one Avhich may possibly be urged against the use 
of this contrivance, is the chance of the displacement of the presenting 
part, by the expansion within the uterus of the fundus of the bao; ; but, 
in so far as experience has gone, in the hands of the inventor, or of those 
who have adopted his process, it does not appear that this objection has 
been experienced in actual practice. For our part, we have repeatedly 
had occasion to use the apparatus, and, so far as a limited experience 
may entitle us to form an opinion, we can, in every respect, corroborate 
the assertions Avhich have been made in its favor. 

The methods of inducing premature labor which have been above 
detailed do not, it need scarcely be said, embrace all that have been 
suggested and practised. At a very early period of the controversy, 
galvanism was looked upon by some as an agent from which important 
results might be expected ; but, although this is a powerful and un- 
doubted provocative to the uterine contraction in some cases, it is so 
uncertain that its use has now been abandoned, — as has also been the 
case with regard to many other expedients, from which at one time 



552 INDUCTION OF PREMATURE LABOR. 

brilliant results Avere looked for. Scanzoni has suggested an ingenious, 
but rather fanciful, method, depending upon the well-known sympathy 
which exists between the mammai and the uterus. He has applied — 
and in two cases, at least, with success — an apparatus of the nature of 
an exhausting syringe, or sucking-pump, over the nipple for about two 
hours, the irritation thus produced being propagated by sympathy to the 
uterus. Most of the other methods suggested are either modifications of 
processes already described, or are not of sufficient importance to require 
special consideration. 

The condition of the ovum, the uterus, and the system generally, in 
reference to this operation, are obviously points of no little importance. 
The question of viability or non-viability of the foetus having been 
determined by the period of pregnancy, the fitness, anatomically and 
physiologically, of the maternal parts, and, indirectly, that of the general 
system of the mother, naturally attract attention. In deciding upon the 
operation, we necessarily resolve upon a proceeding which, in a manner, 
takes nature unawares. The condition of the cervix at various periods 
of pregnancy has been fully referred to in a previous chapter. It is 
but natural, therefore, that we should anticipate difficulties, in proportion 
to the extent to which the case is removed from the full term of gestation. 
But, in practice, it is truly wonderful how nature seems to adapt herself 
to the exigencies of the case ; for, not only do the parts yield, to an 
extent upon which mere speculation would not entitle us to rely, but the 
whole system seems to lend itself to our purpose. The breasts enlarge 
and milk is secreted, after the seventh month at least, and often earlier, 
for the sustenance of the infant, just as if pregnancy had run an uninter- 
rupted course. The dangers of parturition may be to some extent, but, 
in truth, are scarcely sensibly augmented ; nor are certain after-effects 
of mature parturition — which have yet to be detailed — much, if at all, 
more likely to accrue. 

This brings to a conclusion Avhat is generally termed Operative Mid- 
wifery. The various modes of procedure which in this and previous 
chapters have been described, do not, of course, include every skilful tour 
de main which the experienced or ingenious practitioner will, under special 
or peculiar circumstances, adopt. The object of the author has been 
rather to point to general principles, than to elaborate details to which 
the increasing scientific accuracy of the art is daily giving precision. 



OCCLUSION OF THE OS. 553 



CHAPTEK XXXV. 

LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

Rigidity of the Os. — Use of Ancesthetics and of Belladonna. — Forcible Distension. 
— Incision if Os Occluded. — Effects of Uterine Displacement. — Abnormal 
Conditions of the Vulca and of the Vagina: Piigidity : Persistent Hymen: 
Cicatrices from Sloughing: Treatment of these Conditions. — Vaginal Throm- 
bus. — Uterine Polypus; Management of where it obstructs Labor. — Ovarian 
jfumors. — Fecal Accumulation in the Piectum : Rectocele. — Distension of the 
Bladder: Cystocele. — Stone in the Bladder an Occasional Impediment. — 
Hernice. — Other Tumors which may impede Labor. — Malignant Disease of the 
Canal. 

Ix treating of the management of natural labor, various obstructions, 
arising from the condition of the soft parts, were necessarily alluded to. 
The form under which obstruction of this kind most frequently presents 
itself is that of Rigidity, either of the os uteri or of the perineal struc- 
tures. Generally spealdng^ this is an occurrence which exists quite in- 
dependently of any diseased condition of the parts, and is, in fact, a 
purely functional lesion, yielding, as all experience has shown, to time, 
or to blood-letting, anaesthetics, and the warm bath. Such obstructions 
as this may exist in every conceivable degree, from that which causes 
but a trifling delay, to the more obstinate forms which only yield after 
long-continued, and possibly exhausting labor. But, in addition to these, 
there are yet other cases in which the obstruction of the os is of a more 
serious nature, depending either upon peculiarity of structure or actual 
disease ; and it is in cases such as these, as was before mentioned, that 
the force of the uterine contraction has been so great as, in some rare 
instances, to separate the os and cervix, in the form of a ring, from the 
rest of the uterus ; or, in some more common way, to produce rupture of 
the organ. 

There are some cases in which there seems to be actual occlusion of 
the OS, such as is sometimes observed in the unimpregnated uterus. Im- 
pregnation in the case of an absolutely occluded os is as impossible as 
that the normal function of menstruation should be carried on ; and 
therefore, we assume, in such cases, that the closure must have taken 
place subsequently to the entrance of the seminal fluid. It is, of course 
possible, that the os may remain open to a very limited extent, and yet 
the state of the tissues render distension impossible, so as practically to 
constitute an impediment as insurmountable as actual occlusion would be. 
In cases of anteversion of the gravid uterus, which is associated with 
pendulous abdomen, one result of the displacement is that the os uteri is 
tilted upwards and backwards beyond the reach of the finger, a condition 



55-4 OBSTRUCTIONS TO LABOR. 

■which might readily enough be mistaken for occlusion, unless the ob- 
server should take the precaution to introduce the hand Avithin the vagina, 
so as to explore thoroughly that part of it which is towards the hollow of 
the sacrum. Injuries, the result of former labors, the indiscriminate use 
of cauterants, and some other similar causes, may give rise to a species 
of callous rigidity, which is scarcely to be overcome by any means short 
of actual incision ; and in the worst cases of all, in which the tissues are 
the seat of induration from cancerous disease, the barrier may be so im- 
passable as to render necessary the desperate expedient of the Ceesarean 
Section. 

In byegone times, the treatment of simple rigidity of the os consisted 
in the free use of the lancet, the administration of tartar emetic, and the 
employment of the warm bath. That these agents have the effect, in 
most cases, of overcoming such rigidity is certain ; but, in the present 
day, anaesthetics are always preferred as being safer, simpler, and equally 
reliable. Chloroform is usually preferred, but recent observations would 
seem to indicate that ether is safer, while the effect produced by chloral 
hydrate is no less marked. [Under certain circumstances the prepara- 
tions of opium are among the most useful remedies that can be adminis- 
tered for the relief of rigidity of the os. This remedy is particularly 
useful in weak women with irritability of the nervous system and deficient 
muscular force. Such persons often have ineffective pains for a long 
time, the os uteri being scarcely affected by them. A dose of morphia, 
or any other preparation of opium, large enough to secure two or three 
hours' sleep, will often be followed by rapid relaxation of the os. In- 
deed, we have seen a rigid os, which had remained unchanged for hours, 
become relaxed and undergo complete dilatation durmg a couple of 
hours' sleep induced by a large dose of morphia. — P.] Belladonna, in 
the form of injection, is much extolled by the French accoucheurs ; but 
this is an expedient which is to be resorted to with caution, as faintness, 
headache, vertigo, and the other constitutional effects of the drug are 
apt unexpectedly to be induced. The cases, according to Cazeaux, in 
which belladonna is most likely to do good, are those in which there is 
not rigidity, but spasmodic contraction of the fibres of the neck, an active 
and not a passive force. Although the os may, in ordinary cases, with 
scarcely an exception, be readily detected by the finger, it would appear 
that there are instances in which, although it has been impossible to feel 
it, its presence has been revealed to the eye by the speculum. This at 
least is an assertion which has been made by some whose opinions must 
always command respect ; but it appears to us that the difficulty of 
using the speculum in labor, and the impossibility of recognizing the os 
when it is high in the hollow of the sacrum, must render this mode of 
investigation a very unsatisfactory one. The treatment of labor ob- 
structed in this way may come to be a matter involving considerable 
perplexity. If the os, or the situation where surrounding induration 
marks the point at which it has become occluded, can be discovered, 
mechanical means, such as sponge tents, and the like, must be used for 
its dilatation ; but when no aperture whatever can be distinguished, 
even when uterine action has been in operation for some time so as to 
bear upon the inferior segment of the uterus, no course remains for us 



EFFECTS OF UTERINE DISPLACEMENT. 555 

but to incise the organ at the point where the os is usually found, and 
thus avoid the danger with Avhich the woman is threatened. 

The necessity for such an operation being once recognized, no advan- 
tage, but the contrary, will ensue from delay. Beyond a certain degree 
of uterine effort, all that is essential is the presence of such pains as 
may secure the passage of the head so soon as a channel is opened up 
for it. The effect of delay, indeed, in such a case, would be to incur 
the danger of rupture of the uterus, and to allow the period to pass at 
which the patient is best able to bear the continued strain entailed by 
the ordinary phenomena of propulsive labor. In so far as the opera- 
tion is concerned, the incision should be made from before backwards, 
by a blunt-pointed bistoury, or by a series of incisions radiating from 
the real or imagined site of the occluded os. Great care should, of 
course, be taken not to wound the rectum or bladder ; and the reason 
why the antero-posterior direction is preferred is, that the uterine 
arteries may with certainty be avoided. The incision should be made 
to a limited extent only, for, the breach being once effected, and 
uterine effort beinj; present, the head will, partly by stretching and 
partly by tearing, open a passage for itself as it is forced onwards. A 
number of morbid conditions of the os and cervix have occasionally 
been observed to cause serious obstruction to labor. Of these the 
most important is, of course, cancer ; but there are cases in which 
induration and hypertrophy of the whole cervix, or it may be of the 
anterior lip only, has constituted an impediment scarcely less formidable. 
In some instances, it would appear that the cause of obstruction may be 
an hypertrophied and elongated condition of the cervix, as in a case 
reported by Mr. Roper, in the '' Obstetrical Transactions" for 1836. 
The treatment proper to such a condition would be dilatation by means 
of sponge tents, or by air or water bags. x\bscess and thrombus of the 
lips of the OS have also been encountered as rare impediments to the 
passage of the child. 

The more important displacements of the gravid uterus have already 
been spoken of; and, from the observations then made, the influence 
•which such malpositions may exercise upon the progress of labor may be 
in a great measure inferred. The effect of displacement forwards — ante- 
version or anterior obliquity — of the uterus must necessarily be to throw 
the OS backwards ; and, at the same time, the axis of propulsive action 
deviates from that which is normal in proportion to the extent of the dis- 
placement. If, along with this, there is any contraction of the pelvic 
brim, the result of the misdirected force may be that the head does not 
become engaged in the cavity, and that the anterior and inferior part of 
the uterus is exposed to injurious pressure. This condition of matters — 
which is recognized by a combined abdominal and vaginal exploration — 
may best be remedied by raising the depressed fundus, and maintaining 
it in that position by a bandage. In this way, the axis of the uterus is 
brought more into coincidence with that of the brim, a result which may 
be still further insured by a supine position. 

Posterior and lateral obliquities have also been noted as impediments 
to delivery, but to these unnecessary prominence is given by most Conti- 
nental authorities. In the former case, the os will probably be discerned 



556 OBSTRUCTIONS TO LABOR. 

in front, behind the symphysis ; and, in lateral obliquities, the os will be 
directed to the side opposite to that to which the fundus is inclined. 
Although practical difficulty from these obliquities is rare, it may happen 
that the head remains above the brim, while the shoulder w^hich is lowest 
in the uterus, slipping down, becomes the presenting part. 

An abnormal condition of the vulva and vagina, congenital or other- 
wise, may sometimes cause serious obstruction to the course of labor. 
Union of the labia and nymphoe may exist to a greater or less extent; 
and, as the smallest possible vaginal orifice is all that is essential to im- 
pregnation, an obstacle of this kind, whether congenital or the result of 
cicatricial union and contraction, may require the aid of art. The per- 
sistence of the hymen is another condition of a similar kind, which has 
sometimes been observed to such an extent as to constitute an impassable 
barrier. An extreme rigidity of the external parts has been noticed, 
chiefly in the case of women who become pregnant for the first time, 
either at an advanced age or very young. This rigidity of the perineum 
will generally yield to the vigorous pressure of efficient labor pains ; but 
it sometimes happens that the resistance is obstinate, and requires assist- 
ance. In all these cases, incision should not be practised until the head 
has descended to the perineum, and then only to such an extent as may 
be absolutely necessary, remembering always that a trifling incision thus 
made will be extended as the head advances. 

Our anxiety, in such circumstances, would be chiefly directed to the 
perineum, a laceration in which may, as we have seen, prove a very seri- 
ous matter, by running back into the rectum. In order to avert such a 
catastrophe, therefore, we should make the incision, not in the middle line, 
but on either side, so as to direct the tear laterally and not posteriorly; 
and, even when such lacerations may have a formidable appearance at the 
moment of birth, they will rapidly contract, and a few days afterwards will 
be no longer visible. If the obstacle depends — whether in the vagina or 
at its orifice — upon contraction which is the result of disease or previous 
laceration, the difficulties of the case may be very great. Not unfre- 
quently the cicatrices are formed of strong ligamentous bands, which 
prevent the distension of the vagina, and may even pass across from one 
side of the canal to the other as imperfect septa. It has been recom 
mended, when this is recognized early, that gradual dilatation should be 
attempted by means of tents or bougies. In the minor cases, the stric- 
ture will ultimately yield before the pressure which, during labor, is 
brought to bear upon it from within; but, in the worst cases, operative 
interference w^ill be required. It has been found that free incision of 
such vaginal cicatrices is apt to be followed by serious hemorrhage. 
What, therefore, is a much safer plan is to act in the same manner as we 
have recommended in incisions practised at other portions of the partu- 
rient canal. A number of superficial incisions, or scarifications, parallel 
to the axis of the vagina, will, when the head descends, yield, and ad- 
mit of tearing, which should be effected to such an extent only as may be 
necessary for its passage. Such tearing is, of course, free from the or- 
dinary risks of hemorrhage ; but a moderate amount of bleeding is, per- 
haps, rather to be desiderated than otherwise, as it will tend to promote 
relaxation of the parts. The division of bands or septa may be con- 



THROMBUS OF THE VAGINA. 557 

ducted upon the same principle ; and it has been recommended that we 
should partially divide them cautiously during the pain, even allowing 
the knife to be forced by the contractions against the obstruction. If it 
does not speedily yield, the finger may be used freely to encourage the 
tearing asunder of these structures, using the knife as little as possible. 
In this way the difficulty will gradually be overcome, and the descending 
head will make its way, or may even be assisted by the forceps. 

The vagina may be very small, or contracted congenitaUy at some part 
of its length, or in its whole extent, — the canal, although sufficient for 
the purpose of impregnation or menstruation, being utterly inadequate 
for the function of parturition. Should such a condition as this call for 
operative procedure, it will be necessary to give relief to the constriction 
by cautiously combining tearing with incision, as in the cases of contrac- 
tion from adhesion, adopting such means as may be best suited to protect 
the adjoining hollow viscera from injury, and a similar mode of proce- 
dure may be found necessary in these cases in which the vagina has be- 
come seriously encroached upon, as the result of sloughing from whatever 
cause and the cicatricial contraction which subsequently ensures. 

Again, the soft parts may be the seat of diseased conditions, giving 
rise to tumors of any portion of the canal, which may prove mechanical 
impediments to labor. CEdema of the vulva has already been men- 
tioned as an occasional result of pregnancy, and it would appear that 
sometimes this exists to such a degree as to constitute a mechanical 
obstruction. Thrombus of the vagina— which is observed both during 
gestation and after delivery — occasionally, by its unusual development, 
bars the passage of the head, and at the same time presses injuriously 
upon the bladder and the rectum. These tumors, depending as they do 
upon the rupture of bloodvessels, usually make their appearance sud- 
denly — a diagnostic feature which is of considerable importance. Some- 
times the blood infiltrates the cellular tissue, and at other times it is 
accumulated within cavities which it forms for itself; and, in the latter 
case, a certain degree of modified fluctuation will probably be observed, 
while the pain by which the original tumefaction has been accompanied, 
and the bluish color which the tumor exhibits externally, will generally 
suffice to indicate, with precision, the nature of the case. 

The prognosis of vaginal thrombus, whether occurring during preg- 
nancy, labor, or at a more advanced period, is very serious. " Of sixty- 
two cases," says M. Deneux, " which have come to my knowledge, the 
mother has succumbed in twenty-two ; and, with the exception of a single 
case, the children in those twenty-two cases were lost." In cases which 
prove fatal, sudden loss of blood seems to be the most common cause of 
death ; but in those instances in which this primary risk is avoided, gan- 
grene or suppuration may ultimately lead to a fatal result. We have at 
present nothing to do with the treatment of thrombus occurring during 
pregnancy or after labor ; but in those cases in which it constitutes an 
actual obstacle to delivery, nothing is open to us but free incision, which 
may be made in the most dependent portion of the tumor, and of such a 
size as its dimensions may seem to render necessary. Among the other 
tumors which may be encountered during labor, we may mention, in 
addition to those which have already been detailed, phlegmonous enlarge- 



558 



OBSTRUCTIONS TO LABOR. 



merits, cysts, syphilitic vegetations, and such tumors as have been 
figured by Martin in his "Atlas," as due to hypertrophy or degeneration 
of the nymphae and preputium clitoridis, — all of which must be managed 
on ordinary surgical principles. 

Polypoid tumors, springing from the uterus, may sometimes constitute 
very serious obstacles to delivery, as is shown in Fig. 199. The mere 
existence of a tumor of this character is not, hoAvever, to be accepted as 
evidence of a condition which absolutely prohibits the passage of the 
child, as much will depend upon the mobility as well as the compressi- 
bility of the tumor. In a case published by Dr. Beatty, to which Dr. 
Churchill refers, " the tumor was so large and apparently so fixed, that 
Csesarean Section was anticipated ; nevertheless, at the time of labor, it 
was elevated sufficiently to allow of the birth of the child without any 
assistance." In some cases of polypi with a narrow pedicle, the effect 

Fig. 199. 




Uteriue Polypus as an Obstacle to Delivery. 



of continued pressure and extreme effort has been to detach the growth, 
and expel it in advance of the child. The management of such cases 
will depend, in a great measure, upon the conditions already mentioned. 
If, for example, it is movable, and the head has not yet descended into 
the pelvis, so as to render such a result impossible of attainment, we 
should try, as has in some instances been done with success, to push the 
tumor upwards during the interval between the pains, and retain it in its 
elevated position until the head takes precedence of it in its descent. 
Should this, however, fail, the nature of the tumor being undoubted, the 
proper treatment will be to remove it, Avhich may be effected with the 
least possible risk, by means of the wire dcraseur. 

In some cases of ovarian disease, the tumor, instead of developing 
upwards, as is usual, in the direction of the abdominal cavity, falls down- 



OVARIAN TUMORS. 



559 



wards into the pouch of Douglas, betwixt the rectum on the one hand, 
and the uterus and vagina on the other. Such a condition will, no doubt, 
as a rule, give rise to abortion or premature labor ; but, as the system 
is often slow to respond to such influences, it may happen that pregnancy, 
under these circumstances, goes on to the full term. In such a case as 
this, the obstacle, mechanically speaking, is much the same as in the 
case of the uterine polypus just alluded to (see Fig. 200). The ana- 
Fig. 200. 




Ovarian Tumor obstructing Delivery. 

tomical relations of a tumor such as this are widely different from the 
other case, as it is to be reached, not within the vulvo-uterine canal, but 
by perforation of the peritoneum either from that side or from the rec- 
tum. Such tumors vary considerably both in size and form, and the 
first point, therefore, upon which it is necessary to decide is, whether or 
not it is of such a nature as to constitute an impossibility, or merely a 
difficulty, in the passage of the foetus. This will depend in a great 
measure upon the structure of the tumor. Such growths are, as is well 
known, most frequently cystic in their nature, and, consequently, admit 
of a considerable amount of flattening, which would also be encouraged 
by the elasticity of their walls. The benefit of this mechanical advan- 
tage may, however, be lost by the nature of the pressure which is exer- 
cised by the advancing head ; for, if the higher part be firmly pressed, 
as is quite possible, between the head or other presenting part and the 
pelvic brim, so as to bring the walls of the cyst into complete apposition, 
the lower portion may bulk still more prominently during a pain, and be 
rendered at that moment harder and more resistant. We should not, in 
such a case, confine ourselves to vaginal exploration, but endeavor, by 
the introduction of one or more fingers into the rectum, to ascertain the 



ObO OBSTRUCTIONS TO LABOR. 

nature of the case, with such precision as may be possible under the 
circumstances. 

The treatment applicable to these cases must obviously depend upon 
the information to be derived from such examination as may be practi- 
cable. If the volume, seat, and nature of the tumor seem to encourage 
the belief that the forces of nature may prevail, we should do nothing 
further than to make sure, by securing an empty condition of the blad- 
der and rectum, that no extraneous influence exists, which may further 
complicate the acknowledged difficulties of the case. If, however, a purely 
expectant treatment should not result in the progress which we desire, 
it will be proper to attempt to push the tumor beyond the upper bound- 
ary of the pelvis ; but, if it should show a tendency to fall back, which 
will generally happen during the interval between the pains, we must 
attempt to retain it in such a position as may enable us to apply the for- 
ceps or to introduce the hand for the purpose of version, in which latter 
case the arm of the operator in the vagina will prevent the tumor from 
again descending towards the floor of the pelvis. 

In cases in which the descent of the head, or the existence of adhe- 
sions, renders any displacement of the tumor impossible, it is even of 
greater importance that we should recognize, what is not always an easy 
matter, whether or not it is cystic. If so, and we leave it to nature, the 
result will probably be either rupture and escape of its contents into the 
cavity of the peritoneum, or a violent inflammatory action, the result of 
pressure. The puncture of such cysts from the vagina, as advised by 
Merriman, has been practised with perfect success; and, in the present 
day, with our experience of the greater safety of the aspirator trocar, 
we would, in such a case, operate with an even greater prospect of a 
successful issue, removing of course as far as possible the fluid contents 
of the tumor. Complete success can, under such circumstances, only be 
counted upon when the cyst is unilocular; but, when it is a multilocular 
cyst, or the contents are unusually thick, it has been found necessary, in 
order to lessen the tumor, to incise from the vagina, a mode of procedure 
which, although dangerous, is probably less so than the doubtful results 
of the accidents which we have indicated as likely to supervene, if the 
case be left to nature. Some have proposed puncture by the rectum; 
but, as the dangers of this operation are greater than the other, it ought 
to be rejected; unless, perhaps, under very peculiar circumstances. 

When the tumor is solid, the difficulties of the case are greatly in- 
creased. In such a case, it being impossible to push it back, we have to 
balance the chances of embryotomy or the Csesarean Section against an 
operation which has for its object the separation and removal of the 
growth. Merriman recommends that, if we can convince ourselves of the 
absence of serious adhesions, we should proceed by the method of extir- 
pation ; but, putting aside the difficulty of determining this point before 
the operation has actually been commenced, we fear that this procedure 
can seldom be justifiable. If the tumor be of such a size as to leave an 
available gap of an inch and a half or two inches in the pelvis, the ope- 
ration of craniotomy would, we think, with the improved appliances now 
at our command, afford a much better prospect of success ; and, even 
when this hope is denied us, the Cyesarean operation, if performed early, 



VAGINAL CYSTOCELE. 561 

or, possibly, Gastro-Elytrotomy, would give the patient a better chance 
than removal of the tumor, and might at least have the effect of saving 
the child. The result of all such operations has, however, been extremely 
unfavorable. 

An accumulation of hardened feces in the rectum has occasionally 
proved a very serious obstacle to labor. Such a condition can, of course, 
only happen where there has been great carelessness and neglect of the 
functions, so as to permit the lodgment of such a mass within the rectum 
as may actually bar the advance of the head. The treatment obviously 
indicated in such a case, is the relief of the bowels by means of emollient 
enemata ; but should these fail, owing to the size or extreme induration 
of the mass, it may be necessary to scoop out, or otherwise remove the 
contents of the rectum, and in one way or other the tumor will usually 
be dissipated without difficulty. The only other affections of the rectum 
which may be supposed to impede delivery are scirrhus, which has seldom 
been observed of such a size as to form a serious obstacle, and rectocele, 
in Avhich the lower part of the gut protrudes into the vagina. 

On the opposite side of the vaginal canal, the condition of the bladder 
may exercise an obvious influence on the progress of the case. The 
importance, not only in operations, but in ordinary obstetrical practice, 
of attending to that viscus, so as to protect it from the effects of disten- 
sion, is a point, as has already been repeatedly mentioned, of the highest 
importance, in regard to which neglect not only endangers the bladder 
itself, but may also cause an obstruction to labor. Cystocele, as an im- 
pediment, consists m the protrusion of the neck and lower part of the 
bladder in the direction of the vag-ina, formino; a tumor of such size as to 
prevent the passage of the head. The idea usually entertained of this 
seems to have been that it is due, in a great measure, if not entirely, to 
neglect of the usual precautions for insuring the evacuation of the 
bladder ; but we are at one with Dr. Tyler Smith in supposing that this, 
although a possible cause, is certainly not the usual one. Prolapse of 
the bladder is by no means an uncommon, and is sometimes a very trouble- 
some affection, in Avomen who have borne large families ; and, when a 
woman in whom this occurs becomes pregnant, we have reason to fear that 
unless special care be taken at the time of delivery, difficulties may pos- 
sibly arise. The impediment will best be obviated by the opportune use 
of the catheter ; and if the cystocele already exists as an obstruction, 
care must be taken to pass the catheter backwards into the tumor, or to 
raise and press upon the latter so as to insure its evacuation. Caution 
must be exercised in the diagnosis of this affection, for it has happened 
that the fluctuating sac has been mistaken for the membranes, and per- 
forated with the vicAv of giving exit to the liquor amnii, the assumed 
cause of the obstruction. It has also been mistaken and punctured, in a 
case reported by Merriman, for a hydrocephalic presentation. 

An interesting illustrative case, in which the tumor was of consider- 
able size, is narrated by Madame Lachapelle. "The first thing," she 
writes, " that attracted attention was a pediculated tumor, about the size 
of an egg, which, projecting a little from the vulva, seemed to be attached 
to the anterior and right wall of the vagina, about its middle part. The 
pedicle was about an inch and a half in thickness, and the tumor con- 
36 



562 OBSTRUCTIONS TO LABOR. 

tained a fluid which could be completely pressed out of it through the 
pedicle, when we were able to feel an aperture with thickened borders, 
which appeared to me to communicate with the bladder. In reference to 
the position of the woman, it was found that the tumor increased in size in 
the erect posture ; it often disappeared after micturition, and was always 
retracted under the influence of a cold bath. The uterine contraction 
increased the volume of this hernia, and the head, in its descent, pushed 
it in advance, and stretched it strongly. I reduced it after having emptied 
the bladder, and I recommended the pupils to support it with two fingers 
during each uterine contraction. The head soon cleared the passage, and 
itself retained the hernia, and the labor terminated happily." 

A urinary calculus may, of course, coexist with the pregnant state, 
but will usually produce no effect, mechanical or otherwise, upon the 
progress of gestation. In rare instances, however, it has been found 
that the stone has been so placed as to be imprisoned in the lower segment 
of the bladder by the pressure of the head of the child against the pubis. 
The advance of the head still further tends to confirm this position, and, 
ultimately, the stone, encroaching as it does, upon the calibre of the 
pelvic canal, constitutes a serious impediment to delivery. The circum- 
stance in which a calculus is most likely to be an obstacle to labor, is 
when it is complicated with vaginal cystocele — an anatomical condition 
of the parts obviously favoring the descent of the stone by gravity. 
Smellie gives among his cases that of the wife of a coal porter, who, 
having long suffered from the symptoms of stone, became pregnant. She 
was attended during labor by a midwife, who recognized the presence of 
a hard body in advance of the head, but, her resources being limited, she 
was content to wait and watch the progress of events. Ultimately, a hard 
and rounded substance of considerable size was extracted from the vagina, 
which, on examination, was found to be a calculus of large size. The 
removal of the obstacle admitted of the immediate passage of the child ; 
but the incontinence of urine, which remained, was, undoubtedly, due to 
vesico-vaginal fistula — an accident then considered irremediable. 

The treatment of all such cases will consist — if the period has not 
already passed when this may be effected — in attempting to push the 
stone upwards into that part of the bladder which is above the brim, and, 
if necessary, retaining it there during the intervals between the pains, 
until the head shall descend, so as to prevent its slipping down again. If 
the head has already made some advance in its passage through the pelvis, 
it may still be possible to push up the stone by operating during the in- 
terval between the pains, if only we can displace the head a little so as 
to admit of its passage upwards. But, if the calculus is so placed that 
it is impossible to dislodge it from its position, the case may become a 
very serious one, as the only remaining resource will then be the removal 
of the body w^hich prevents the accomplishment of the function of partu- 
rition. The safest mode of procedure, as to its immediate results, would, 
under such circumstances, probably be the dilatation of the urethra and 
the extraction of the stone. Such an operation is, however, open to two 
objections. In the first place, it can only be safely performed slowly, a 
condition which obviously does not suit the exigencies of the case ; and, 
again, it leaves most unsatisfactory results in a long continuance of in- 



VARIOUS TUMORS. 563 

continence of urine. It is probable, therefore, that the most judicious 
course would be, when the obstacle seems such as to preclude the possi- 
bility of safe delivery by the forceps or turning, to perform the operation 
of vaginal lithotomy, cutting down upon the stone through the neck of 
the bladder, and removing it in the usual way. The operation of litho- 
trity has also been suggested ; but, in so far as we are aware, it has never 
been practised. 

Certain rare forms of hernia may coexist with pregnancy, and may 
even form impediments to the termination of labor. It is, it must be con- 
fessed, very unlikely that such tumors should, in any considerable degree, 
oppose the passage of the child ; but there undoubtedly exists the more 
indirect, but not less serious danger, which arises from compression or 
strangulation of a hernial tumor, wherever situate. Such hernias have 
been observed in the posterior part of the pelvis, the bowel, or omentum, 
or both, having descended, in the first instance, into the cul-de-sac of the 
peritoneum which lies between the vagina and the rectum, making its way 
downwards in the same direction, until it may ultimately protrude at the 
perineum, and form a perineal hernia ; while, if it bulges into the vagina, 
it is a vaginal hernia. The protrusion may also take place from a dif- 
ferent quarter, the bowel passing along the canal of Nuck, and ultimately 
forming a tumor in the labium of either side, which is anatomically analo- 
gous to scrotal hernia in the male. The diagnosis of these tumors will 
seldom cause much perplexity, if the case is one of ordinary enterocele ; 
but, if it be constituted by the omentum alone, the absence of gurgling 
on reduction, and of other characteristic signs, may invest the case with 
considerable obscurity. The treatment in all cases is the same, — to prac- 
tise the taxis, and maintain the displaced viscus in its proper situation 
while labor is in progress, with the object, as we have said, partly of pre- 
venting the possibility of mechanical obstruction, but mainly w^ith the 
view of protecting the displaced parts from injurious pressure. 

The various tumors which have been described do not, it need scarcely 
be said, embrace all the possible varieties of abnormal growth, which may 
be encountered as impediments to the progress of labor. Fibrous, fatty, 
or encysted growths may spring from any portion of the cellular tissue 
of the pelvis. The direction which these most frequently take, is that 
of the recto-vaginal pouch ; but they have also been observed in the sides 
of the canal, and even between the uterus and the bladder. To distin- 
guish such abnormal structures from those which have their origin in the 
tissues of the various organs which are situated in the pelvis will always 
be a matter of difficult}^ sometimes of impossibility. Everything will 
depend upon the mobility and compressibility of such tumors, and the 
result, in many cases, will simply be an increased difficulty in the passage 
of the child, the forces of nature ultimately overcoming the obstacle. 

But, in some cases, the volume and immobility of the tumor may be 
such as to preclude the possibility of any such favorable result ; and, in 
that case, we may be forced to adopt such surgical means as may with 
the least risk get rid of the difficulty. If it is a cyst, it will be proper, 
therefore, to evacuate its contents ; and, if solid, its size, shape, and the 
nature of its connection, by adhesion or otherwise, must serve as our 
guides to such operative measures as, on general principles, the nature of 



564 OBSTRUCTIONS TO LABOR. 

the case seems to demand. Excision of such tumors is, of course, under 
these circumstances, an operation which is attended with peculiar risk : 
it has been practised by an incision through the vaginal walls ; and, in 
some other cases, with success, by a more extensive incision involving the 
thickness of the perineum. The worst cases are those in which the size 
of the tumor, its immobility, and the great extent of its adhesions, render 
such operations impracticable ; and, in these nothing will be left to us 
beyond the more desperate resources of operative midwifery. 

Frequent reference has been made to malignant tumors as obstacles to 
delivery. The nature of this fearful class of diseases is such that the 
impediment may have its origin in the bones or ligaments ; or may spring 
from the uterus, bladder, rectum, or any conceivable part or structure of 
the pelvic contents. Moreover, from a tumor of trifling size, it may 
attain dimensions which are only limited by the capacity of the pelvic 
canal ; and the tendency of all malignant growths to invade contiguous 
textures frequently places the case in a category peculiar to itself, inas- 
much as it is impossible to isolate it either for the purpose of removal or 
dislodgment. In the advanced state of the ordinary forms of malignant 
disease, the hardness of the tumor, the infiltration and infection of sur- 
rounding tissues, the binding together of the parts, the presence of ulcera- 
tion, and the existence of marked cachexia, will generally render diagnosis 
a matter of no difficulty. 

In the initiatory stage of the disease, the diagnosis will naturally be 
more obscure, and in cauliflower excrescence, and the rarer funguoid 
forms of malignant disease, the symptoms are very diflerent from those 
above indicated, but are still sufficiently characteristic to enable us to 
form a definite opinion as to the nature of the case. From what has 
been said, it will be obvious that no surgical rules can be laid down for 
the management of cases such as these, whether the tissue primarily in- 
vaded be the labia, the uterus, or any other portion of the canal. The 
nature of the case, and the extent of the obstruction can only be our 
guides. Malignant atresia has repeatedly been overcome by incision of 
the diseased structures, with success as regards delivery of the child ; but, 
in those cases in which the disease is extensive, it Avill only remain for us 
to decide between the forceps and the other more serious operations. 



HYDROCEPHALUS. 565 



CHAPTEK XXXVI. 

OBSTRUCTION DEPENDING ON THE STATE OF THE OVUM. 

Hi/drocephahis : Diagnosis of: Maim gement of such Cases. — Spina Bifida. — Ob- 
struction from Ascites., HydrotJiorax, and Distension of the Bladder. — Gaseous 
Distension from Putrefaction. — lumors springing from the Foetus — Anchy- 
losis of the Joints., and Intra-uterine Fracture. — Premature Closure of the 
Sutures. — Unusual Development of the Foetus. — Special Difficulties in Plural 
Pregnancy : Loclced Twins. — Monsters ichich impede Delivery : The Siamese 
Twins, and other Similar Cases. — Shortness of the Umhiliccd Cord as an 
Obstacle. — Dorsal Displacement of the Arm. — Thickness and Persistence of 
the Meinbranes. 

It not unfrequently happens that, although the maternal parts are, in 
every respect, normal, and the position everything that may be desired, 
the relative proportions which should exist between the ovum and the 
canal are disturbed by an abnormal condition of the former. The pecu- 
liarities in structure w^hich give rise to mechanical obstruction of this 
nature, consist, mainly, of an increase in size, whether of the whole 
foetus or of some of its parts, arising, in one class of cases, from faults of 
development, and in another, from the effects of intra-uterine disease. 
The peculiarities alluded to may affect either the foetus itself or some of 
the other parts of the ovum : no reference is here made to malposition 
of the foetus, a subject which has already received full consideration. 

The diseases of the child from which such unfortunate conditions spring, 
are those in which some one of its parts become the seat of such an in- 
crease in size as to constitute an impediment, more or less serious, to the 
progress of labor. Of these the more important are hydrocephalus, 
fluid distension of the great cavities of the trunk, and tumors of various 
kinds springing from its external surface. Hydrocephalus is, of all such 
affections, not only, as might be expected, the most important from a 
mechanical point of view, but is so also in point of frequency. One form 
of this affection, or rather one which has been by many writers 
erroneously described as such, is an effusion of fluid beneath the scalp or 
pericranium, and consequently, exterior to the cranial cavity. Examples 
of this, which has been termed external hydrocephalus, are very rare, 
and have usually been found to be associated with a general condition of 
infiltration affecting the w4iole of the external tissues of the foetus. It is 
a condition which usually implies the death of the foetus, so that any 
serious impediment from a child which is in all probability putrid need 
scarcely be anticipated. 

The internal variety, or what is known as true Hydrocephalus, is a 
much more serious as well as a more frequent occurrence, and may exist 



566 OBSTRUCTIONS TO LABOR. 

to such an extent as absolutely to preclude the possibility of delivery by 
the unaided efforts of nature. In this case, the fluid, which is effused 
within the cranial cavity, varies greatly in quantity. In those instances 
in which the quantity is small, the difficulties of parturition may not be 
materially augmented, as the compressibility of the head is, in conse- 
quence of the nature of its contents, relatively increased — a condition 
which obviously tends to facilitate its passage, and compensates for the 
actual increase of bulk. Owing to this indeed, and associated probably 
with ample pelvic diameters, very large heads have been known to pass 
naturally. In some cases, the head, in consequence of the quantity of 
fluid which is poured out by the morbid process, attains enormous dimen- 
sions. When the disease is slow in its progress, the flat-bones become 
developed to a very unusual extent, but when more rapid, the deposit of 
bone does not keep pace with the distension of the head, and the latter, 
under such circumstances, may present itself under the form rather of a 
bag of fluid than of an ordinary cranial presentation. The rule certainly 
is that the process of ossification fails to overtake that of fluid distension, 
and a marked characteristic, therefore, of hydrocephalic heads is that 
the sutures and fontanelles are more apart than usual. 

When the size of the head is considerable, and the symptoms conse- 
quently well marked, the recognition of hydrocephalus is generally easy 
enough. The presenting part, which in these cases is arrested above 
the brim, is found to be less resistant, and less convex than usual. The 
sutures and fontanelles are, however, to be distinctly felt; and, if we 
can feel that the former are agape, and the latter of larger size than 
usual, with more or less of a feeling of fluctuation, there will be little 
room for doubt. The existence of a large posterior fontanelle is particu- 
larly characteristic ; and, if the hand be fully introduced, the great size 
of the head will be recognized. 

This applies, of course, to those cases only in which the cranium pre- 
sents at the brim. It often happens, however, in such instances, that 
the same reasons which, under ordinary or normal circumstances, cause 
the head to adapt itself to the smaller end of the ovoid cavity of the 
uterus, operate by so determining the presentation, that what is here 
the larger extremity of the foetal oval lies in the fundus of the uterus, 
the pelvic extremity being downwards. The conditions being thus absent 
upon which alone our diagnosis can depend, no suspicion is entertained 
as to the nature of the case ; and it is only when, after the breech and 
trunk have passed the brim, and the head is there arrested, that suspi- 
cion is awakened, and the existence of hydrocephalus possibly recognized. 
For, in such cases, it is by no means an easy matter to make sure of 
this, as it is only a limited portion of the occiput which can be reached 
with the finger; but, if we find the pelvis of average dimensions, and are 
able to recognize a large head with its bones loosely articulated, and a 
trunk and limbs somewhat less in size than usual, we shall probably take 
these facts as sufficient collectively to warrant a confident decision. 
Another symptom which, when the head presents, has been insisted upon 
by Blot, is that while the head is absolutely arrested at the brim, the 
whole body of the foetus is higher relatively to the abdominal walls ; 



TREATMENT OF HYDROCEPHALUS. 507 

and, therefore, the pulsations of the foetal heart may be recognized by 
the stethoscope as high, or even higher than, the level of the umbilicus. 

The nature of the obstruction depends, not merely upon the quantity 
of fluid effused with the cranium, but also upon the development of the 
flat-bones, and the degree of compression of which the head is suscep- 
tible. These conditions may, however, with truth be regarded as sub- 
sidiary to another, arising from the manner in which the head descends 
and becomes engaged in the pelvds. A mere bag of water (and the 
head is sometimes actually reduced to this condition) may, so long as it 
remains unruptured, be an impediment as insurmountable above the 
brim as an absolutely solid mass would be. But, if the conformation of 
the parts, and other conditions, should permit of the engagement of such 
a tumor, so that its lateral walls are efficiently compressed by the pelvic 
canal, matters are so completely altered, that an elongated oval, contain- 
ing an equal bulk of fluid, may get through the passage, while one which 
is spheroidal, or, with reference to the aperture of the brim, transversely 
ovoid, cannot even enter. It is, no doubt, on this principle that those 
cases have occurred, of which we read, where a child has been bom 
alive, with ahead measuring, in its circumference, twenty-two or twenty- 
four inches, whereas the normal standard is, on an average, about 
thirteen inches and a half. 

While recognizing these facts, however, the operator must beware of 
trusting to such a result, unless he finds that the pelvis is ample, and 
the cephalic tumor is pointing downwards, thus giving indications of 
moulding itself to the pelvic canal. There are, perhaps, few contingen- 
cies in the practice of midwifery in which a careful and early diagnosis 
is of greater importance than here ; for, however revolting the operation 
of craniotomy may be to a well-regulated mind, the more fearful risk of 
delay must be from the first admitted into our calculation. In seventy 
cases, collected by Dr. Thomas Keith, rupture of the uterus occurred in 
so large a proportion as sixteen ; while, in every one of the five cases 
reported by Dr. Robert Lee, in his " Clinical Midwifery," the mother 
was lost either from rupture of the uterus, or inflammation of the organ, 
facts which — independently of many others corroborating the conclusion 
— point significantly to the danger that, in such cases, attends delay. 

The indications of treatment are, from one point of view^, sufficiently 
obvious ; but our action will, in no small measure, be swayed by the 
presence or absence of symptoms indicating the vitality of the child. 
If the child is dead, w^e do not require to wait for absolute certainty of 
diagnosis. Evidence of serious obstruction is all that, in such a case, 
we would think necessary to warrant us in perforating and giving vent 
to the fluid wdiich is pent up within the cranium. But, when the child 
still lives, the responsibility which attaches to the operation is greatly 
increased, and the error -which, in such cases, is most likely to be com- 
mitted is that the operator may w^ait until the mother has become 
exhausted or the child has died ; whereas, he ought to have sooner 
recognized the fact that the passage of a living or viable child was 
impossible, and have acted upon the principles w^hich we have already 
laid down as applicable generally to cases of destructive or sacrificial 
midwifery. The immediate effect of craniotomy, in hydrocephalus, is, 



568 OBSTRUCTIONS TO LABOR. 

by permitting of the escape of a large amount of fluid, to reduce the 
bulk of the head to an extent much greater than obtains when perfora- 
tion is practised under other circumstances. It may happen, as in some 
recorded cases, that the operation, as well as the diagnosis, may be 
complicated by the coexistence of what has been described as " exter- 
nal," along with internal hydrocephalus, when it may be necessary to 
evacuate the external accumulation of fluid before piercing the cranium. 
To such an extent does the distension sometimes occur that several pints 
of fluid have been removed by simple perforation, when collapse of the 
cranium takes place, so as to permit of the expulsion of the head under 
the influence of the natural efl'orts. 

It has happened that, after perforation, and evacuation of the serum 
contained within the cranium, the child has been born alive ; so that, 
although the chances of a child surviving under such circumstances 
may be considered as extremely small, it has been urged by Cazeaux 
that the operation should be so performed as, if possible, to prevent 
laceration of the cerebral structures, and the inevitable sacrifice of the 
child which must thus ensue. It has been suggested, therefore, that, 
on this account, the ordinary perforating apparatus should be rejected, 
and a simple puncture efiected, by means of a trocar or guarded bistoury, 
sufficient to penetrate the membranes through a fontanelle or suture, and 
nothing more. From what has already been said, it will be apparent 
that, in the minor cases, any mode of procedure which may promote 
lateral compression of the head may, with possible advantage, be adopted 
in preference to craniotomy. With this in view, therefore, it is usual 
and proper to attempt delivery, in the first instance, by means of the 
forceps, when the compressing power of that instrument may be employed 
to a somewhat greater extent than is usual ; but, if this fails, and the 
circumstances of the case are otherwise such as to preclude the hope of 
expulsion by the unaided efforts of nature, the more serious operation 
should be practised without delay. 

If the difficulty should arise in a presentation of the pelvic extremity, 
— which occurs, according to Scanzoni, in one in five of all cases of 
hydrocephalus, — the operation is one which cannot be performed with 
the same facility. Various modes of procedure have been suggested as 
applicable to such instances. It has been found possible, for example, 
to reach the cranial cavity through the mouth, by piercing the base of 
the skull through the vault of the palate ; and, in other cases, it has 
been successfully practised through the orbit ; but what, in such cases, 
we would recommend, in preference to either of these methods, would 
be direct perforation behind the ear, should it be possible to reach that 
part of the cranium. It has sometimes happened that the tumors which 
are connected with osseous deficiency of the cranium or vertebral column, 
and which are known to the surgeon as Encephalocele and Spina Bifida, 
have attained such dimensions as to prove an obstacle to delivery ; in 
which case it may be necessary to perforate the tumor and evacuate the 
fluid which it contains. 

Eff"usions into the other great serous cavities of the body, although 
less frequent in their occurrence than hydrocephalus, render delivery 
equally impossible. In ascites the development of the abdomen is 



ASCITES, ETC. 569 

sometimes enormous, and is revealed by the fluctuation as well as by 
the size. The only affection of a similar kind with which we might 
possibly confound it, is distension of the bladder, which, when the 
urethra is impermeable, may possibly give rise to a tumor of great size, 
which may require tapping equally with the peritoneal effusion. The 
description of such a case was communicated by M. Depaul to the 
Acadeaiie de Medecine, and this, it may here be observed, is, along with 
other similar cases, one of the most important points of evidence upon 
which phj^siologists rely in supposing that the urine of the foetus is 
naturally evacuated into the amnionic cavity. When the peritoneum of 
the child is distended with fluid, so as to prevent its passage, that cavity 
must be pierced by a trocar, and the fluid which it contains drained away 
by the canula. 

Hydrothorax is still less frequent in its occurrence. It is indicated by 
an enlargement of the thoracic region and intercostal bulging, and may 
require punctures to be practised between the ribs, with precisely the 
same object as in the other case. In all these cases, the operation of 
perforation should be so performed as to avoid injuring the internal 
organs ; for not only would this entail unnecessary mutilation, but might 
defeat our object by preventing the escape of the fluid. The develop- 
ment within the body, as a result of putrefaction, of enormous quantities 
of gas, is a fact familiar to the medical jurist, and may take place within 
the cavities of the foetas as well as under other circumstances. In some 
rare instances, in consequence of this, severe laceration of the maternal 
parts has occurred, with a fatal result ; and in other cases, labor has been 
terminated in consequence of a rupture of the foetal tissues giving issue 
to the pent up gas. No hesitation should, in such a case, deter the ope- 
rator, as the evidence of the child's death will be otherwise complete, 
and he is bound to act so as to protect the mother from risk. 

Tumors of various kinds may spring from the surface of the foetus, or 
be developed in connection with some of the internal organs, and may, 
by attaining unusual size, render labor impossible of natural termination. 
Tumors have, for example, been observed, which had their origin in the 
liver or the kidneys, enlarging the trunk to an enormous extent, so as 
absolutely to prevent its passage, and render indispensable the operation 
of embryulcia, in the course of which it has been found necessary to 
break up the tumor, and remove it piecemeal before we can complete the 
delivery. Another rare condition of the foetus, which may be a very 
serious obstacle, is anchylosis of the articulations, and the same may be 
said of those cases in which there has been intra-uterine fracture as the 
result of violence, the limbs having united at an angle. It is diflicult to 
say what, under such circumstances, should be done, if the condition has 
been recognized before birth ; but, in so far as anchylosis is concerned, 
we may assume that the joints will probably be united while the limbs 
are flexed upon the body in the usual attitude of the foetus, and that the 
conditions are, therefore, not altogether unfavorable to the natural termi- 
nation of labor. A more serious impediment has been in some instances 
found to arise from premature closure of the sutures and fontanelles. 
This, in a perfectly normal condition of the parts otherwise, may give 
rise to great delay, if not impaction, by its being impossible for the head 



570 OBSTRUCTIONS TO LABOR. 

to adapt itself in any way to the shape of the passage ; and, as Dr. 
Tyler Smith has observed, the dangers of such a condition are not limited 
to the mechanical hindrance to delivery, but it may be looked upon as an 
extremely probable, if not certain cause of idiocy, by preventing the 
development of the brain. 

The child sometimes, even when not retained within the uterus beyond 
the ordinary period of gestation, attains a size so greatly in excess of 
the ordinary standard, as to cause a very difficult or dangerous labor. 
If we take, as has already been stated in round numbers, the average 
weight of the fully-developed foetus as seven pounds and a quarter, we 
are not astonished when we find in practice, that when it approaches 
twelve pounds, the labor is, unless the maternal parts are of unusual 
capacity, a slow and painful one. But, when it reaches fourteen, fifteen, 
or nearly eighteen pounds (as in one well-known and authentic case al- 
ready cited) it is difficult to conceive how by any possibility such a 
child could pass. If, however, we look closely at children which are 
much above the average, it will be observed that the increase in w^eight 
is to a great extent due to the development of fat beneath the skin, so 
that it is the trunk and limbs, rather than the cranium, which are increased 
in size, and it is on this account that we find the powers of nature suffi- 
cient for the expulsion of the child. If the increase of bulk has been 
the result of a protracted sojourn of the foetus in the womb, the case will 
probably be more serious in its nature ; and, certainly, in all such, we 
may be sure that the maternal as well as the foetal mortality will be in- 
creased relatively to the size of the child. Statistics, indeed, tell us 
that this is the case, even as regards the comparatively trifling difference 
which exists between the male and female cranium. It is, however, very 
rare that, in the absence of pelvic deformity, cases of unusual foetal 
development may not be delivered by the forceps or turning, which we 
may term the minor operations of midwifery. 

The occurrence of Plural Pregnancy may in various ways give rise to 
difficulty, and even to serious obstruction. In the case of multiple 
pregnancy, the products of conception may be disposed in almost any 
manner compatible with the limits and mechanical conditions of the 
uterus ; but it does not appear that any great difficulty has been met 
with, in these instances, unless one or more of the children have been 
in a faulty position. The same remark applies to twin pregnancy. In 
the latter, the two children are most frequently observed to occupy each 
a side of the womb, with the cephalic extremities downwards, and one 
head somewhat in advance of the other. In a very considerable number, 
the head of one child and the breech of the other present ; while, in rarer 
instances, the feet of both may be downwards, or one or both may lie 
transversely in the womb. In plural pregnancy the uterus, no doubt, 
acts at a certain mechanical disadvantage, inasmuch as its propulsive 
force is communicated to the foetus which is lowest in the uterus — not 
directly, as in single pregnancy, but indirectly through the body of the 
other. But, as has been well observed, this disadvantage is usually com- 
pensated for by the comparatively smaller size of the children. The 
cases where delay is most likely to occur are those in which the breech 
of the first child is the presenting part ; and, as this descends, the diffi- 



PLURAL PREGNANCY. 5T1 

culties, as in ordinary cases, will be greatly increased by any unusual 
resistance at the outlet. 

As has already been observed in an early chapter, when the subject 
of plural pregnancy was under discussion, there is very often a period of 
considerable delay after the birth of the first child. This is probably 
due, in many instances at least, to uterine exhaustion ; and the pause 
which then ensues is a perfectly natural condition, which we should 
rather encourage, as it enables nature to recruit her exhausted forces, 
and thus bring them into renewed activity when the period arises for the 
expulsion of the remaining contents of the uterus. The recommendations, 
therefore, which are given by some authorities as to the circumstances 
which warrant, in such cases, operative interference, should be received 
with great caution, and only acted upon when the conditions are such as 
to indicate beyond the possibility of doubt, that it is proper to aid or 
precipitate labor in any way. 

But the most serious mechanical difficulty which may arise in the 
course of labor in plural pregnancy, is what has been described in the 
case of twin pregnancy as " locked twins." When the membranes are, 
as has previously been shoAvn (see Figs. 93 and 94), so arranged that 
each child lies in its own sac, the expulsive forces act, even under such 
mechanical disadvantages, so as to expel one child first, and to leave the 
other still enveloped in its own amnion. The first birth thus takes place 
without any particular difficulty. But, if they are inclosed in one 
amnionic cavity, the parts of the two may fall into such a position as to 
make delivery a matter of the greatest possible difficulty. The most 
common form of locking is when the first child presents by the breech, 
and passes downwards up to a certain point without impediment ; but 
when serious obstruction occurs, and we are thus led to make a more 
particular examination, it is discovered that the descent of the head is 
obstructed by the presence in the pelvic cavity of the head of the second 
child, which has caused the chins to be so hitched together that the com- 
pletion of the first birth is rendered a matter of impossibility, unless the 
twins are small or the pelvis large. If, under such circumstances, we 
pull upon the body of the partially born child, we only make matters 
worse by locking them more firmly together. In some cases, when the 
condition of the parts is such as to admit of it, it may be possible, by 
pressing back the heads in the direction of the uterus, to unlock them, 
and thus to permit of their descent singly. But, if this endeavor should 
fail, it will become evident that the only way to disengage them is to 
break up the compound wedge and so admit of the passage of one or 
other of the children. 

This may be effected in two ways, as has been well demonstrated by 
Dr. Barnes ; either by decapitating the first child, which we have the 
least chance of saving owing to the pressure which is being exercised on 
its umbilical cord, or by perforating the head of the second child, so as 
to admit of the passage of the first. In the first case, the body which 
occupies the vagina will at once pass, and its head receding will admit 
of delivery of the second child by the forceps ; and in the second case, 
which is only justifiable when we have reason to believe that the upper 
or second child is dead, we allow the perforated head to be flattened to 



572 OBSTRUCTIONS TO LABOR. 

such an extent as to admit of the passage of the head of the first, through 
the diameters which the operation has succeeded in reducing. This 
latter plan has the obvious advantage over the former that the difficulty 
of extracting the severed head is thereby avoided. 

There is another form of locking, in which both of the twins present 
by the head. The first head passes in this case without difficulty into 
the pelvis, but the head of the second, descending along with the trunk 
of the first, prevents further progress by presenting the bulk of a head 
and a thorax simultaneously at the brim. The mechanical management 
of such a case as this may be a matter of even greater difficulty than the 
former. Perforation of the head which is within reach can obviously do 
no good, so that it is only by guiding the perforator upwards to the 
second head, and reducing its bulk in the usual way, that the operation 
may be, with any hope of success, adopted. In such cases, as has been 
shown by the experience of Dr. Graham Weir and others, it may be 
possible, by dexterous manipulation, to obviate the serious difficulties 
which exist. It has been found practicable in this way to extract by the 
forceps the child which originally presented while the head of the other 
was pushed aside by an assistant. External manipulation has also suc- 
ceeded in skilful hands in forcing onwards the head which was situated 
highest in the pelvis, and thus causing it to take precedence of that 
which originally presented. All cases of locked twins are, however, 
serious complications, and are therefore with justice looked upon as 
among those dangers against which the operator should be prepared. 

The first or second child may present in a preternatural manner, — by 
the shoulder for example, as has before been explained, — and in such a 
case, we have to beware of the mistake, which has been committed, of 
seizing the wrong foot or feet when the hand is introduced for the pur- 
pose of turning; or it may happen, as in a case narrated by Madame 
Lachapelle, that when turning has been successfully eifected, and the 
breech extracted, locking by the chins is the perplexing result. It is to 
be borne in mind that, in plaral pregnancy, there is a greater risk of 
hemorrhage, owing to the extent of surface to which the placenta is at- 
tached. And, in cases in which there is an inosculation of the cords, 
there is, at an earlier stage, another special risk, if we leave the placental 
portion of the severed cord untied. 

Various forms of Monstrosity give rise to difficulty in the course of 
labor ; and in extreme cases it is only possible to complete delivery by 
embryotomy or the Csesarean Section. We have here, of course, nothing 
to do with such departments of teratology as are illustrated by acephalic 
or anencephalic monsters ; and still less with those which are anopic, or 
cyclopic, as such conditions present no mechanical obstacle whatever. 
The many different forms of ectopy present, as a rule, little or no diffi- 
culty ; but in the more complete form, as in a case figured by Vrolik, the 
whole of the thoracic and abdominal viscera are external to the child, 
and may impede its passage. It has been observed, in another form of 
monstrosity, that the liver projecting through the unclosed umbilicus 
(^Exo)nphalo8) has, by its augmented size, caused a serious impediment, 
which might well be expected to bar the progress of ordinary labor. 

The forms of monstrosity which are, from the point of view of mechan- 



MONSTROSITY, 



573 




Double-headed Monster 



ical obstruction, the most serious, are those Fig- 201. 

in which the two children in a twin preg- 
nancy become fused together to a greater 
or less extent, the union or fusion being ana- 
tomically symmetrical. Infinite as the vari- 
eties of such cases are, this rule is never 
violated, and is indeed the only possible 
method of which the laws which regulate 
development can admit. Thus, we have 
union of sacrum to sacrum, occiput to oc- 
ciput, or abdomen to abdomen; but never 
sacrum to occiput, or abdomen to sacrum. 
There may be one perfect trunk with two 
heads, as shown in the annexed cut, which 
closely resembles a case of this kind, which 
we had an opportunity of seeing with Dr. 
George Mather ; but the union may be even 
higher than the cervical vertebme, when we 
have more or less fusion of the crania. In 
such a case as the one here represented, in 
which the size of the various parts was 
rather more than is usual at the full time, 
a mere glance will suffice to show, not only 
that labor must necessarily be impeded, but 
that it is scarcely possible, in a normal 
condition of the parts as regards size, that a natural termination should 
take place. 

In a case which has been described by Meigs, one head descended first, 
and was delivered. It then became fixed under the sub-pubic angle, and 
the ultimate process of delivery was precisely similar to what takes place 
in the spontaneous expulsion of a transverse presentation, the trunk, 
breech, lower limbs, and, lastly, the second head, passing through the 
external parts. In the case to which reference was made above, delivery 
was accomplished with the greatest possible difficulty. It was a primi- 
parous case, and the breech was the presenting part, everything going 
on well until the heads entered the pelvis, when complete arrest took 
place. The crotchet failed completely, and as Dr. Mather thought that 
the head was too high to use the perforator with safety, he attempted, by 
means of steady traction, to bring it more within reach, when, to his as- 
tonishment, two heads descended, situated obliquely, with reference to 
each other, in the pelvis so that the one was a little in advance of the 
other. In this way, and after long-protracted efforts, the heads, which 
were quite the average size, passed. The pelvis was, as might have been 
expected, a capacious one : but even this does not make the case less in- 
teresting. The mode of delivery described by Meigs is generally sup- 
posed to be the only possible way in which such, a child can be born with- 
out perforation or decapitation ; but the case above given, which is ex- 
tremely rare, if not unique, shows that if the other be the rule, it has at 
least, like many other rules, exceptions. 

In that class of cases in which there is one head and a double condi- 



574 



OBSTRUCTIONS TO LABOR 




Double Monster, 



tion of the lower parts of the body, the mechanical difficulty is not likely 
to be so great, as it is much more conceivable that two pelves could be 

sufficiently pressed together du- 
ring their descent as to admit 
of their simultaneous passage 
through the pelvis of the mother. 
The monster here shown, from 
one which was described by Dr. 
J. Gr. Walter, has three legs and 
four arms. Complete fusion of 
the pelves was found on examina- 
tion after death to have occurred, 
and there was also union of the 
ensiform cartilages. On first 
sight it may appear that de- 
livery, in such a case, would be 
even more difficult than of the 
ordinary two-headed monster ; 
but a little consideration will 
show^ that the possibility of one 
head at a time passing along the 
pelvis, gets rid of the greatest 
difficulty which attaches to this 
variety. The probability of a 
transverse presentation is in such a case, however, very strong ; and this, 
of course, w^ould be a most unfortunate circumstance, as turning and bring- 
ing down the feet would inevitably bring the heads together, and thus 
make matters worse than ever. 

It has occasionally happened that twins, more or less completely 
united or fused together, have been born alive, and have even attained 
maturity. In the most familiar instance of this kind — that of the well- 
known Siamese twins — there was a mere band of union ; but it is indeed 
difficult, in regard to this and other similar cases, to conceive even the 
possibility of birth, unless after mutilation or putrefaction ; in fact, we 
can only suppose in reference to such, that the material pelvis has been 
of unusual capacity, that labor has occurred prematurely, or that both 
of these conditions have been combined. Another comparatively rare 
form of monstrosity has been mentioned under " Twin Pregnancy" as 
monstrosity by inclusion ; and, in this case, the tumor of the perineum, 
which contains the foetus in foetu, may be a serious obstacle. It will 
readily be understood — and the more so as they are of extremely rare 
occurrence — that such cases may cause great perplexity to the accou- 
cheur, and, whether the diagnosis is accurately formed or not, cannot 
fail to be a very serious barrier to delivery. So various, however, are 
the forms under which monstrosities present themselves, that it is impos- 
sible to lay down any general rules which might serve for the guidance 
of the practitioner. In a considerable number of cases, it has been 
found necessary to decapitate, eviscerate, and otherwise mutilate one or 
both of the united twins or repeated parts, before it has been possible to 
relieve the woman of the contents of her womb. Care must, it need 



SHORTNESS OF THE UMBILICAL CORD. 575 

scarcely be added, be taken, not only to insure correctness of diagnosis, 
but also not to operate rashly, for there can be no doubt that Ave are 
morally bound to consider the life of monsters as scrupulously as that of 
the foetus in normal pregnancy. 

Shortness of the umbilical cord is generally mentioned in systematic 
works as a possible mechanical hindrance to delivery. It is certain, 
however, that such an occurrence is extremely rare. We do not mean 
to assert that the cord is not occasionally short, but merely that this 
effect of shortness is not one which is likely often to take place. Cases 
do occasionally occur, in which the actual length of the funis does not 
exceed a few inches, a condition which, if the placenta is normally 
situated, must imply delay in delivery, rupture of the cord, premature 
separation of the placenta, or inversion of the uterus. Some have denied 
that any impediment whatever is in this way likely to arise ; but the 
evidence which has been advanced in favor of the contrary view seems 
pretty clearly to show that in cases of protracted labor, which have only 
terminated after rupture of the cord, the cause of the delay must have 
been the extreme shortness of the link which bound the foetus to its 
utero-placental attachment. 

What is certainly of more frequent occurrence than actual shortness 
of the cord is — what has, mechanically, precisely the same effect — coil- 
ing of the cord round the child. In such cases, there is usually not only 
no shortening of the cord, but an undue length of it, which is the original 
cause of the coiling which takes place round the neck more frequently 
than round any other part of the foetus. This artificial shortening is, 
we believe, of more frequent occurrence than is usually supposed ; and 
ever}^ practitioner knows that few things are more common in practice 
than to find one, two, or more coils of the funis round the neck of the 
child. The exact stage of delivery at which arrestment from this cause 
is most likely to occur, depends upon the length, or the length exclusive 
of coils, of the cord ; but, as a rule, it would appear that it is seldom 
that much inconvenience is complained of until the stage of expulsion 
approaches, when, for the first time, the cord is put upon the stretch, 
and pain is, probably, to some extent complained of in the region of the 
uterus. It has been stated, as a symptom during labor of shortness of 
the cord, that if the placenta is attached at its usual site, a depression of 
the fundus occurs at every pain, the rounded form being restored in the 
interval. That such an occurrence may take place, it would be impos- 
sible to deny ; but it seems to us pretty clear that this is one of the 
instances, of which illustrations are too frequent in medical literature, 
where what we may call a theoretical symptom is set down as a real or 
practical one. 

It has frequently been observed, when the cord was coiled round the 
neck of the child, that progress was for the first time arrested during or 
after the birth of the head. This has probably, to some extent, led to 
the routine practice of disengaging the coils as soon as their presence is 
detected — although the main cause undoubtedly is a dread of suffocation 
of the child by pressure on the respiratory passages. It has in some 
instances been found necessary, when the cause of the obstruction was 



576 OBSTRUCTIONS TO LABOR. 

evident, to cut the cord, a course of procedure which must recommend 
itself to the operator when the nature of the case is obvious. Caution 
should of course be exercised to prevent hemorrhage from the cut ves- 
sels, by placing a ligature speedily on the umbilical side of the section ; 
but it has been pointed out that a slight discharge is rather favorable in 
its effect than otherwise when asphyxia is threatened, a condition which 
may very probably be found to exist, along with the semi-apoplectic con- 
dition depending upon interruption to the circulation in the great vessels 
of the neck. In breech presentation, or after the performance of podalic 
version, the cord sometimes is found surroundino; the trunk or entanded 
among the limbs, whence it will be proper to disengage it if possible, 
and, if this cannot be eifected, to cut it, rather than run the risk of ob- 
struction in what, for the child at least, is always a critical labor. After 
such cases, it is proper to introduce the hand into the vagina to ascer- 
tain that there is no inversion of the uterus, unless the state of the 
organ, as observed through the abdominal walls, is in all respects satis- 
factory. 

A rare and curious cause of obstructed labor has been shown by Sir 
James Simpson to arise from dorsal displacement of the arm. This may 
occur either in pelvic or cephalic presentations. In the former case, 
which is more frequent, it is probably due to an improper and imprudent 
dragging upon the limbs, the tendency of which is, as has formerly been 
shown, to allow the arm to pass up alongside of the head. If one or 
other arm should, in this process, get behind the head — as is still more 
likely to occur in unskilful turning — it is not difficult to understand how 
the arm may get behind the neck and beneath the occiput, and thus con- 
stitute an impediment of a very serious character, the limbs being so 
placed that its reposition is a matter of no inconsiderable difficulty. The 
arm will, in such cases, generally lie against the symphysis pubis, and it 
will therefore only be practicable to dislodge it, if we can succeed in 
pushing the parts upwards, so as to leave sufficient room, between the 
occiput and the upper part of the symphysis, to admit of such manipula- 
tion as may effect our object. In Simpson's case, the presentation was 
one of the head, in which the arm had in some peculiar way which it is 
difficult to understand got on to the nape of the neck, and was thrown 
transversely across the pelvis. The course suggested by him for the 
management of such cases is to bring the arm down by the side of the 
head, as its complete reposition above the brim would probably be im- 
possible, and allow labor to go on in this way, the presentation now being 
an ordinary head and arm case ; but we are impressed with the idea that 
the mode of procedure adopted by Dr. Jardine Murray in similar cir- 
cumstances, which simply consisted in turning, meets much more fully 
the difficulties of the case. 

There is but one other condition arising from the state of the ovum to 
which we think it necessary here to refer. This is unusual thickness 
and resistance of the membranes, which, sometimes, while things are 
otherwise going on favorably under efficient uterine contraction, abso- 
lutely stops the progress of the labor. It is needless to recapitulate 
what has already been said as to the management of the membranes ; 



UTERINE INERTIA AND PRECIPITATE LABOR. 577 

the only important point being that, before we decide on rupturing them, 
which will at once bring this difficulty to an end, we should be sure that 
the proper function of the membrane has been effected in producing dila- 
tation of the OS. No danger will accrue to the child, so long as the 
presence of the liquor amnii protects it from injurious pressure. 



CHAPTEE XXXYII. 

UTERINE INERTIA AND PRECIPITATE LABOR. 

Irreriularities in the Progress of Labor ; often due to Intestinal Derangement. — 
Inertia : Injluence of Temperament, Climate, -^fj^i Emotion, Excessii-e Dis- 
tension, Premature Rupture of the Membranes, etc. — Influence of Irregular 
Uterine Action : Uterine Tetanus. — WigancV s Classification : Different Grades 
and Varieties of Inertia. — Treatment of Inertia ; if from Over-distension or 
Displacement of the Uterus ; if from Intestinal Derangement : Various Modes 
of Exciting Reflex Uterine Energy : Stimulants as a rule to be avoided: Use 
of the Eorceps in Inertia: Ergot; its Natural History, and Physiological 
Effects : Rules for its Use in Midwifery/ : Other Oxytocic Agents. 
Pkecipit ATE Labor: Causes obscure: Apparent Connection with Menstrual 
Excitement. — Labor may be Precipitate from Deficient Resistance. — Danger 
of Rupture and Laceration of the Uterus. — Tendency to Post-partum Hemor- 
rhage. — Treatment: Empty Bowels: Opium: Sources of Reflex Irritation to 
be carefully avoided. 

In no two cases of labor is the course of the process precisely similar, 
although the vast majority are from first to last perfectly normal. No- 
thing is more familiar to the accoucheur than the sudden and unlooked 
for changes which occur in the course of an ordinary case. In one 
instance, the tardy and inefficient progress which has characterized it 
during many tedious hours gives place, without any very obvious reason, 
to efficient and even violent action, which brings the act to a precipitate 
termination; while, in another, the safe and steady progress which has 
led us confidently to anticipate a speedy issue of the case, is provokingly 
interrupted by a failure of expulsive power — and that too, not unfre- 
quently, when the second stage of labor is nearly at an end. Such 
occurrences as these are generally of no great importance, and resolve 
themselves most frequently into a trial of patience, or a moment of hurry 
and excitement ; but cases do now and again occur, in which a failure 
of action, or violence of propulsive force, demands prompt and energetic 
attention. 

It has very frequently been observed that, in these matters, much 
depends upon the temperament and constitution of the mother ; so that, 
in members of the same family, in persons of similar temperament or 
37 



578 UTERINE INEETIA. 

constitutional power, and to some extent in those of similar social posi- 
tion, there will often be observed a certain resemblance in the character 
and progress of the labor. In some cases, in which the balance between 
power and resistance is in any way disturbed, it would almost appear as 
if nature availed herself of some special compensating condition which 
the exigencies of the case had called into play. The woman, for exam- 
ple, whose health has been impaired by chronic disease, or in whom the 
constitutional vigor and tone is naturally feeble, has, as a rule, com- 
paratively weak uterine action, and always deficient voluntary force ; 
but yet the labor runs a normal course, for the want of tone in nerve 
and fibre favors relaxation of the parts, and thus, proportionately and in 
a compensatory manner, diminishes the resistance. In women, moreover, 
of this temperament, the anatomical peculiarities of the sex are generally 
well marked, and the ample and shallow pelvis thus offers a comparatively 
trifling resistance to the passage of the child. If, however, we contrast 
with this the tail, vigorous, and muscular woman, we find that in the 
latter there is a very general tendency to the male type of pelvis, involv- 
ing a tardy passage of the child through the pelvic canal. May we not 
infer that it is in some degree in compensation for this that she is fur- 
nished with muscles so powerful, and constitutional vigor so marked, to 
enable her to overcome the greater resistance which in a feebler frame 
would constitute an insurmountable barrier ? 

There are many morbid conditions which, exercise an influence more 
or less marked on the progress of parturition, to which we have had 
occasion more particularly to refer. We may here mention one cause, 
in regard to which no doubt can possibly be entertained, as leading both 
to tardy and precipitate action on the part of the expelling powers. 
This is the condition of the intestinal canal, any irritation of which 
may not only excite powerful reflex contraction, but may cause irregular 
uterine action, and in other cases may arrest it altogether ; this being 
one of many reasons why tardy and precipitate labors are always con- 
sidered together. An attentive observation, from a physiological point 
of view, of the phenomena which accompany parturition, and more par- 
ticularly of the nervi-motor action of the uterus, will suffice clearly to 
show that there are many different ways whereby the forces upon which 
the act of birth depends may be disturbed or thrown out of gear, with 
the result, in one class of cases, of a labor which is too rapid to be safe, 
and, in another, of an arrest in the process which may prove a source of 
danger to the mother as well as to the child. It is, indeed, upon a cor- 
rect appreciation of the physiological phenomena referred to that a sound 
and judicious treatment can alone be based. 

Inert Labor. — It will be inferred from what has just been said that, 
in some constitutions, there is a natural tendency to tedious labor by 
reason of a deficiency in the expelling power. Within certain reason- 
able limits, this calls for no treatment, and is attended with no risk ; but 
when these limits are exceeded, the case is to be considered as abnormal. 
Besides general debility, from Avhatever cause arising, there are other 
conditions which have been observed to increase the liability to inefficient 
uterine and expulsive action. Thus, climate and season exercise an in- 
fluence Avhich, although far from uniform, is sometimes obvious, the 



INERT LABOR. 579 

relaxing effect of a high temperature, in those instances, enfeebling the 
nervous and muscular tone ; and it has even been stated that the result 
of long residence in the tropics has a permanently enervating effect, which 
may be manifested subsequently in temperate latitudes. Another cause 
is sometimes found to exist in the age of the woman, and in cases of pre- 
cocious pregnancy this is occasionally very distinct. In women, again, 
who become pregnant for the first time in advanced life, it is well known 
that labor, as a rule, is tardy ; and, although the idea usually entertained 
is that this is due mainly to increased anatomical resistance, there can 
be no doubt that, in a certain proportion of cases, it depends upon defi- 
cient force. 

In those who have borne many children in rapid succession, the action 
of the uterus is often found to become enfeebled towards the close of the 
child-bearing epoch, probably because the organ has not had sufficient 
time for rest, and for the gradual development of those structural changes 
which succeed delivery, during and after the period of involution. The 
influence of emotional causes, although marked, is generally temporary ; 
as is often seen on the arrival of the accoucheur, when it arises from 
fear. Any sudden alarm, startling intelligence, or anything wdiich may 
give rise to sudden emotion, may produce precisely the same effect; and, 
although, as a rule, the uterus in such cases will, after an uncertain in- 
terval, resume its function, it occasionally happens that the pause is so 
long, or occurs at such a critical period in the labor, that it is necessary 
to have recourse to art to expedite or complete the delivery. The various 
displacements of the uterus, which act by altering the axis of expulsion, 
are often considered under this head ; but that, which is a purely mechani- 
cal cause of delay, has already been referred to in a previous chapter. 
What is here implied by inert labor, has reference, almost exclusively, to 
a faulty condition of the expulsive forces, in which they are abnormally 
feeble and inefficient ; and this feebleness of contraction may either exist 
throughout the whole period of labor, or may come on, more or less ab- 
ruptly, in the course of a case which had, up to that time, progressed in 
a manner leaving nothing to be desired. 

The Causes upon which a failure of uterine action depends embrace, 
in addition to those above mentioned, certain conditions of the parts, 
more or less strictly morbid. To these attention must be given, as it is 
manifest that a mere routine treatment, adopted without an intelligent 
reference to the circumstances of the case, must necessarily often fail of 
its object, and may sometimes only tend to make matters worse. Exces- 
sive distension of the uterus, by thinning the walls of the organ beyond 
ordinary limits, is one of the conditions to which we refer. The effect 
of dropsy of the amnion, for example, may in this way interfere with 
the due action of the organ ; and, in such a case, less good will be derived 
from the exhibition of agents which excite the uterus to contract, than 
from rupturing the membranes, and thus allowing the uterine wall to come 
into contact vfith the surface of the child, when it will in all probability 
be roused to active energy. 

The death of the child was believed by Baudelocque to weaken mate- 
rially the uterine contractions ; but Dubois asserts, and modern accouch- 
eurs generally agree with him, that when the woman is in good health, 



580 UTERINE INERTIA. 

the death of the child exercises no influence whatever, in the way of 
enfeebling uterine action, and that if it sometimes happens that labor 
goes on more slowly when the child has ceased to live, this is to be ac- 
counted for by the fact that the death of the child is probably the result 
of some disease of which the mother has been the subject, and that, con- 
sequently, her forces have already been weakened. The prem.ature 
rupture of the membranes, and consequent discharge of the waters, very 
generally cause a tardy labor, but this operates chiefly in the first stage, 
and is mainly due to want of the mechanical dilating power of the bag 
of membranes. Inefficient uterine action has often been observed to be 
associated with undoubted morbid conditions of the organ. Among these 
may be mentioned rheumatism, gout, and neuralgia ; and, in addition, 
congestion and inflammation of the uterus. In so far as congestion and 
inflammation are concerned, while their occasional existence cannot be 
disputed, there can, we imagine, be little doubt that the older writers 
greatly exaggerated their importance and frequency, as an excuse for the 
never-failing remedy of the lancet. A morbid condition, however, of the 
uterine fibre, depending upon some form of uterine inflammation, is a 
possible, and we would venture to say a probable, cause of some of the 
most complete cases of uterine inertia. 

A distended bladder or rectum may, in addition to the mechanical im- 
pediment which it constitutes, act injuriously in arresting uterine action ; 
and it has been observed, in those cases in which pressure on the sacral 
nerves causes cramps in the lower limbs, and the excessive agony to 
which these give rise, that the effect on the uterus is to weaken and not 
to increase its action. Several cases of this kind are cited by Meigs. 

Another eff"ect which is occasionally produced is irregular action, in 
which the whole of the organ is not symmetrically contracted. Irregular 
contractions, as we have already seen, give rise to retention of the 
placenta, hour-glass contraction, and inversion of the uterus ; and, in 
like manner, they necessarily occasion pains, which are inefficient^ inas- 
much as they do not act upon the whole circumference of the ovum. In 
such cases, the pains are more irregular in their occurrence, and the 
suffering, which is severe, is referred at one time to one part of the 
uterus, and again to another. Sometimes, the hand placed over the 
abdomen can detect inequality on the surface of the contracting organ, 
showing what parts are in action and what parts are paralyzed. Under 
the influence of contractions such as these, labor makes little or no pro- 
gress, the bag of membranes does not project in the usual way during a 
pain ; or, if the second stage has been reached, the presenting part of 
the child makes no advance. The woman now becomes exhausted, the 
pulse frequent, and the case may assume a grave aspect. It is to the 
more serious forms of this that the name of " uterine tetanus" has been 
given. 

Inefficient uterine action being thus found to depend upon such a 
variety of causes, it is not to be wondered at that attempts have been 
made to classify the cases. Wigand proposed to divide all into three 
groups. In the first, the womb contracts, not only quite regularly, but 
even to such an extent that the child is bent forwards at each pain, and 
the labor has in general an otherwise normal course ; but this course is 



TREATMENT. 581 

very tedious, and the pains are interrupted by too long intervals. This 
he calls Inertia Uteri. In the second grade, which he describes as 
Adynamia or Atonia Uteris the uterus also contracts in a manner which 
is, so far, quite regular ; but the contraction is incomplete, of short dura- 
tion, and inefficient, and lasts longer at the fundus than in the lower 
segment of the organ. In the third grade, all pain in the uterus has 
ceased, so that, beyond a certain feeble tension, no trace of contraction 
is to be observed ; this condition Wigand describes as Lassitudo, Ex- 
haustion or Paralysis Uteri. Scanzoni proposes that we should draw a 
distinction only between ''primary" and " secondary" inefficient action, 
including, under the first term, all cases in which, from first to last, the 
womb lacks sufficient energy to complete the labor without assistance ; 
and, under the second, those cases in which the contractions were 
originally suilicient, but have failed in the course of labor, so that, in the 
end, all symptoms of primary inertia are manifested. 

We doubt much whether any such system of classification is of value, 
either as a guide to practice or in elucidating the subject ; and we there- 
fore prefer, as embracing all cases of failure of uterine action, the simple 
term Inertia, which is generally used in this sense by English writers. 
Obviously, however, this may exist in any grade, from mere feebleness 
of contraction to absolute paralysis of the uterus. It is proper, in con- 
sidering this subject, not to overlook the possibility of failure in the 
auxiliary expulsive forces ; for it must be obvious that, in the course of 
the second stage, anything which may prevent the efficient action of the 
expiratory muscles must of necessity interfere, more or less, with the act 
of parturition. Acute or chronic pulmonary disease, therefore, as well 
as cardiac or hepatic disorders, and the ascites which often accompanies 
them, may, with other abnormal conditions, so interfere with the 
dynamical phenomena of parturition as very seriously to retard the 
progress of labor. 

Treatment. — A careful consideration of the circumstances above men- 
tioned, as applicable to indvidual instances, will always be our best guide 
to the treatment of those cases in which there is a failure of the vis a 
tergo. An error in the axis of expulsion, which is usually dependent on 
anteversion of the gravid uterus, and therefore does not strictly fall under 
our notice here, may be managed without difficulty, under ordinary cir- 
cumstances, by postural treatment, or by the abdominal bandage, so as 
to bring the axis of the uterus as nearly as may be possible, into coinci- 
dence Avith that of the pelvic brim. Over-distension of the uterine 
cavity, by reason of dropsy of the amnion, plural pregnancy, or any 
other cause, should, if symptoms of inertia develop themselves, be treated 
by rupture of the membranes — and that for reasons which have already 
been stated. 

Although, perhaps, rheumatism of the uterus has been somewhat ex- 
aggerated, as regards its importance as a cause of retarded labor, the 
symptoms should always be taken into consideration, as they are such as 
may divert our attention from the inefficiency of the labor. These symp- 
toms have been well described by the younger Naegele. " Rheumatism 
of the uterus," he says, " is recognized by the following signs. Daring 
labor, and often before it, the uterus is unusually sensitive to contact, 



582 UTERINE INERTIA. 

both from without and from within. The contractions are feeble, short, 
infrequent, and unusually painful, and, in fact, excite as much suffering 
at their commencement as normal pains do at the height of the contrac- 
tion. During the interval between the contractions, the pain does not 
cease. The woman complains of heat, great thirst, and uneasiness ; the 
pulse is rapid, small and hard. In the course of labor, the suffering from 
the pains increases, in proportion as their efficiency diminishes. In favor- 
able cases, the pain ceases for a time, the patient falls asleep, after 
which regular pains soon recur, and continue until the completion of the 
labor ; but when the case is mistaken or unskilfully treated, the labor 
becomes extremely protracted, debility and cramp come on, and rheuma- 
tism passes into metritis." 

In a large proportion of cases, as we have seen, the cause of the 
failure of uterine action is to be found in the condition of the alimen- 
tary canal ; and, on that account, one of the first points that we should 
attend to in all cases is the condition of the primce vice ; and, in like 
manner, and for similar reasons, it is advisable to ascertain the condition 
of the bladder, which sometimes exercises a scarcely less important influ- 
ence on the progress of the case. The effect of relieving a distended or 
irritated viscus is often so striking, that a very common and frequently 
efficient mode of treatment, in cases of uterine inertia, is to throw an 
enema of a stimulating character into the rectum ; and, in fact, so sus- 
ceptible is the uterus, even in these cases, to reflex irritation, that a 
simple enema of warm water will often suffice to awaken its dormant 
energy. 

T)ie action of the organ may also be roused by other expedients of a 
still more simple character. A warm diluent drink is often found to 
have an effect as marked as an enema, and, when the strength has be- 
come in any way exhausted, it will be proper to substitute for this strong 
soup, or even some form of stimulant. The accoucheur can scarcely, 
however, be too cautious in sanctioning the use of stimulants in labor. 
Among the lower classes in Scotland, — where whisky is the panacea for 
all evil, — it will often be impossible to prevent its employment ; but the 
universal opinion of all who have witnessed the indiscriminate adminis- 
tration of stimulants in labor is that the effect, as a rule, is to retard and 
not to advance the period of delivery. The reflex activity of the uterus 
is often aroused by digital examinations, which seem to excite the nerves 
of the cervix, or those which are distributed in some abundance, to the 
tissues of the perineum. Free examination of those parts, therefore, 
which, under ordinary circumstances, is to be condemned, may here be 
practised without hesitation, should the uterus show any symptoms of 
response, a result which will be further encouraged by firm pressure over 
the surface of the abdomen. 

The position of the woman often exercises, at all stages of labor, a 
very decided effect on the vigor and efficiency of the pains ; and, in a 
woman in whom there is an evident tendency, on the part of the uterus, 
to flag in its efforts, the erect posture, by permitting the child to gravi- 
tate toAvards the lower segment, has generally a most beneficial effect ; 
so that it is often proper in these cases to cause the woman to walk about 
the room, even at an advanced stage of labor, in the hope that this result 



USE OF ERGOT. 588 

may ensue. An abdominal bandage, properly applied, will frequently 
be found to contribute much both to the comfort of the woman and the 
efficiency of the pains, on account of the pressure which is thus exercised 
upon the uterine walls, the stimulus which is afforded to the muscular 
fibres, and the increased efficiency with which the abdominal muscles 
are enabled to act ; and, in the same manner, no inconsiderable assist- 
ance may be affi^rded by firm pressure exercised, during a pain, by the 
palm of the hand placed over the abdomen. The effect, indeed, of pres- 
sure of this kind is often very striking, so much so that of late years 
general attention has been directed to this method of treatment as a 
substitute for the ordinary oxytocics. When a tendency to inertia 
exists, something will usually be effected by carefully watching the 
course of labor, encouraging the woman to husband her efforts in the 
first stage, and urging her to make full use, during the second stage, of 
the expiratory muscles, by closing the glottis, fixing the limbs, and 
abstaining from crying during the presence of the pains. 

In a certain number of cases, however, the uterus sinks into a state of 
complete inertia ; or the pains become so feeble that it is evident that 
labor cannot be completed by the unaided powers of nature. This 
condition is one which is often attended with no inconsiderable amount 
of risk both to mother and child. If the failure should occur in the 
early stage of labor, before dilatation of the os has been effected, or the 
head has descended into the pelvis, we may place more confidence in 
nature, and may wait for a reasonable time, in the expectation that more 
efficient action will be set up ; or we may employ the more simple 
means, which have been detailed, with the view of stimulating the 
uterine fibres to contract. When the os is fully dilated, or even, as we 
have seen, at an earlier stage, when we have reason to believe that there 
is dropsy of the amnion, rupture of the membranes is a perfectly proper 
and justifiable procedure, and will often be followed, after a brief inter- 
val, by vigorous contraction. Should this fail, or should the inertia 
have become developed in the course of the second stage, we have then 
to choose between the forceps, or some other mode of operative delivery, 
and the oxytocic agents, of which the ergot of rye is by far the most 
important. 

When the head is low, and the conditions otherwise are such as to 
render the operation both easy and safe, the forceps should, in almost all 
instances, be preferred ; and, in all cases in which the circumstances are 
such as to call for a speedy delivery, we should have recourse to this 
operation, or to turning. But, when the head is high in the pelvis, and 
there is no obvious necessity for rapid delivery, we may resort to some 
of the agents referred to. 

Ergot, which is, as we have said, the most important of the class of 
drugs to which we refer, is to the accoucheur an agent so important and 
so powerful, that we may here interpolate a brief account of it, and of 
the rules which should guide us in its employment in the exigencies of 
ordinary practice. " The Ergot, or Spur," says Christison, " seems to 
affect occasionally all the Graminacege, more rarely the Cyperace^e, and 
sometimes even the Palms. Xo plant, however, presents it so frequently, 
or of such size, as common rye, — the Secede Oereale. It is generally 



584 UTERINE INERTIA. 

thou2!;ht to arise under the influence of undue moisture : and althouo;h this 
condition seems not to be absolutely essential, it is never produced with 
such certainty as in wet seasons, and in districts where the soil is damp, 
rain frequent, and the atmosphere still and misty, especially at the time 
the grain is coming into flower. In these circumstances it is produced, 
according to some, by punctures made by insects in the glumes, while the 
substance of the seed is pulpy; others conceive that it is caused by the 
spawn, or sporidia, of a peculiar species of fungus." The Ergot of rye 
is an irregularly cylindrical body, averaging about an inch in length, and 
slightly curved, like the spur of a cock, — hence the name " Spurred-Rye." 
It has a very powerful toxic action, and gives rise, when taken in large 
quantity, or for a considerable time, to two classes of symptoms, — convul- 
sive and gangrenous. It produces, as has been demonstrated by Dr. Brown- 
Sequard, an influence on the vaso-motor nerves, and thus causes contrac- 
tion of the vessels of the spinal cord, on which account it is frequently 
used in congestive and inflammatory affections of that structure. There 
can be no doubt that it is through that channel that its specific action on 
the uterus is produced ; and it unquestionably is the most certain in its 
action of all the agents hitherto discovered in promoting the contraction 
of the muscular fibres. 

Its action may always be counted upon with more certainty when the 
uterus is fully developed ; so that, in abortion, it cannot be depended 
upon as likely to promote the expulsion of the ovum, with anything ap- 
proaching to the certainty with which, towards the end of pregnancy, the 
uterus responds to its action. Still, although thus comparatively inefli- 
cient, there are no circumstances under which its action on the uterus 
may not be manifested ; so that we not only find it sometimes to act with 
unexpected vigor in the expulsion of an early embryo, but even in the 
unimpregnated organ in the treatment of monorrhagia ; and it has oc- 
curred to us more than once to be able to demonstrate the uterine nature 
of a doubtful abdominal tumor by the contractions produced in it by the 
action of several doses of ergot. It is, however, when labor has actu- 
ally commenced that the action of ergot is most marked ; but there can 
be no doubt that, under other circumstances, it operates, although with 
less certainty, in inducing abortion or premature labor, or otherwise 
initiating uterine action. 

The physiological efl'ects of the drug are, of course, of great interest 
to the accoucheur. We may here pass over, as foreign to our subject, 
its more important toxic effects ; but we may note that it has frequently 
been observed to produce nausea and vomiting, when it has been given 
in the form of enema with perfect success. Subcutaneous injection of 
ergotine has of late been extensively practised, chiefly in the treatment 
of uterine fibroids. The usual effect of ergot on the circulation is a 
diminution both in the frequency and fulness of the pulse, sometimes ac- 
companied with faintness and pallor. In some instances, symptoms of 
cerebral disorder manifest themselves in the form of weight and pain in 
the head, giddiness, delirium, dilatation of the pupil, and stupor; but 
these symptoms commonly follow the uterine contractions, and are usually 
observed in those cases in which an unnecessarily large quantity of the 



USE OF ERaOT. 585 

drug has been administered. That snch symptoms may be manifested is 
enough to show that ergot is always to be used with some caution. 

Its action on the uterus, with which we have more particularly to do, 
is generally observed in from ten to fifteen minutes after the medicine 
has been taken, and is indicated by an increase in the violence and dura- 
tion of the pains. When the full effect of the drug has been produced, 
the pains are quite different from those of normal labor, inasmuch as they 
are absolutely continuous, or at least, without any proper interval, 
although there may be irregular periods of remission. This uninter- 
rupted contraction of the uterine tissue necessarily involves a certain in- 
terference with the utero-placental circulation, over and above what oc- 
curs in the rhythmical contraction of ordinary labor : and it must be ad- 
mitted that the absence of the natural periods of uterine rest may, if 
long-continued, place the life of the child in peculiar jeopardy. This, 
however, has, we believe, been greatly exaggerated. " The ergot," says 
Dr. Hosack, " has been called, in some of the books, from its effects in 
hastening labor, the j^idvis ad jmrtum ; as it regards the child, it may, 
with almost equal truth, be denominated the pulvis ad mortem : for I be- 
lieve its operation, when sufficient to expel the child, in cases where nature 
is alone unequal to the task, is to produce so violent a contraction of the 
womb, and consequent convolution and compression of the uterine vessels, 
as very much to impede, if not totally to interrupt, the circulation be- 
tween the mother and the child." This assertion has been satisfactorily 
refuted by Chapman, Dewees, and others ; but still we are inclined to 
think there is some grain of truth in it — at least in those cases in which 
labor is protracted in spite of strong and unceasing pains. Dr. F. H. 
Ramsbotham supposed that the toxic action of the drug might be extended 
from the mother to the foetus, and the figures which he gives would seem 
to go some way to prove his assertion. Of 36 cases in which he induced 
premature labor by puncturing the membranes, 21 children Avere born 
alive ; while in 26 cases in which labor was induced by ergot alone, 12 
children only Avere born alive. Apart from the fact that such statistics 
are open to many fallacies, we repeat our conviction that the danger of 
ergot to the child has been greatly exaggerated ; and we believe that the 
unsatisfactory results which have been reported have been mainly due to 
the rash administration of the drug, without any reference to the condi- 
tions upon which alone we can rely for a satisfactory result. 

The violence of the contractions produced by ergot is such that we 
are never safe in administering it, unless we are convinced that the 
anatomical conditions are such as to admit of the passage of the child 
without extreme or unusual resistance. To give ergot, therefore, in a 
case of shoulder presentation or of deformed pelvis, when the os is un- 
dilated, or when the soft parts generally are rigid, dry, and undilatable, 
is manifestly wrong ; and, in the first two cases, would amount to mal- 
apraxis in the worst form. As regards the condition of the os, the rule 
is as stated, but is not so absolute. If it were so, it would debar us from 
making use of ergot in the induction of premature labor, where its action 
initiates the commencement of the first stage. Xor, as regards ordinary 
cases, are we to admit that we must always wait until the os has become 
dilated ; for there are instances, in which a dilatable state of the os, 



586 UTERINE INERTIA. 

with a properly lubricated condition of the passages, would be quite suf- 
ficient warrant, in the absence of all action, for the administration of 
ergot. If labor should become arrested before the os has opened to 
some extent, there can be no question of medicinal treatment, as there is 
no risk either to mother or child in the arrest of a labor which has as 
yet barely begun. When the head is low in the pelvis, the forceps, as 
already remarked, will usually be preferred ; and, if any delay should 
arise after the exhibition of ergot, the head being well in the pelvis, it 
may be proper to complete the delivery by instrumental aid. Indeed, 
we believe that the number of cases in which the two may with pro- 
priety be combined is larger than is generally believed. The objection 
to the forceps, in the case of an absolutely inert uterus, is that Ave may 
empty the organ, which then, contracting imperfectly, admits of alarming 
or fatal hemorrhage ; but if we combine the two, the one force will not 
onl}^ aid the other, but the ergot will insure safety after delivery by 
maintaining the Avoman in a proper state of tonic contraction. If the 
contractions are violent, speedy delivery is always to be desired, as a 
considerable number of cases of rupture of the uterus are on record from 
the use of ergot alone. 

The mode in which ergot is usually administered is in the form of in- 
fusion. Two drachms of fresh ergot coarsely crushed may be infused 
for twenty minutes in six ounces of boiling water; one-fourth of the in- 
fusion to be given at intervals of ten or fifteen minutes until distinct 
uterine action is manifested. If, with the second or third dose, the 
desired effect is already produced, it is wrong to proceed further, for the 
result of more than is necessary will only be to increase the tetanic 
character of the contractions and the risk both to mother and child. If 
the quantity above mentioned has been given in four doses without any 
response on the part of the uterus, it will be needless, and indeed impro- 
per, to pursue the treatment further; and cases do, not unfrequently, 
occur, in which the drug seems to be absolutely inert. The infusion 
should always be freshly made ; but the great objection to it is that one 
cannot be sure of the quality of the ergot, more especially if it has been 
kept for any time, when it is apt to become mouldy, or to be entirely 
destroyed by an acarus, which feeds upon it and leaves the grain as a 
mere shell. All these difficulties are got rid of by the use of the Liquid 
Extract or the Tincture of the British Pharmacopoeia, either of which 
may be given in doses of twenty or thirty minims for three or four times 
and at the same intervals as the infusion. Schacht's " Liquor Secalis" 
also contains the active principle of the drug, and may be given in drachm 
doses ; but the liquid extract is the preparation which we can with the 
greatest confidence recommend, as we have had more experience in 
its use. 

Ergot was used by women for hurrying labor long before it was known 
to the profession; and the same remark may be made of Borax, wdiich 
was used by the ancients, and has been much employed in Germany by 
some in preference to ergot, being supposed to be free from the objections 
which attach to ergot as a toxic agent. Cinnamon, Strychnia, and Qui- 
nine have also been employed, as well as numerous other drugs ; and a 
very thorough trial has been made of galvanism, which, although it has 



PRECIPITATE LABOR. 587 

an undoubted effect upon the uterine fibre, is certainly less to be de- 
pended on than ergot, and has therefore fallen entirely into disuse. 

It has often been stated that the various agents of this class should 
not be made use of in the case of primiparae ; but to the judicious prac- 
titioner such a rule is quite unnecessary, as he will not fail to take into 
consideration the greater resistance which naturally obtains in the case 
of a first labor. There is, in fact, if he does not lose sight of the special 
conditions referred to, no reason why he should not avail himself of the 
action of the oxytocic agents in primipar^e as well as in pluripara^. For 
the guidance of the inexperienced practitioner, we will add one caution 
only — that he should not be too eager in his endeavors to bring a case to 
a speedy termination ; for it often happens that a sudden cessation of the 
uterine efforts is merely an indication that the organ is collecting itself 
for more vigorous action and a final effort. 

Precipitate Labor. — Although of less frequent occurrence than failure 
of the expulsive force, the accidents which may accrue in labors which 
are too rapid are scarcely less serious. In the great majority of all such 
cases, there is some peculiarity of constitution or temperament. It has, 
indeed, not unfrequently been observed in the same patient in successive 
pregnancies, and even in different members of the same family. It would 
also appear to be occasionally connected with a morbid irritability of the 
generative system, which may have been previously manifested in undue 
excitement at the menstrual periods. In some extreme instances, the 
action, from the very commencement of labor, is so severe that the patient 
is compelled to bear down from the first. The appearance and expression 
of the countenance, and the state of the pulse, denote a condition of ex- 
citement and suffering which is quite abnormal ; and, in such instances, 
w^e may with some reason dread the occurrence of uterine rupture at a 
stage when we are comparatively powerless to avert it. The pains are 
almost continuous ; and, if the parts are relaxed, the child maybe forced 
through the passage with a rapidity which is almost appalling. In such 
instances, indeed, when the woman is taken unawares, the child may be 
born while she is yet in the erect posture, and dashed upon the floor. 

Although, as we have seen, the usual effect of premature rupture of 
the membranes is to retard labor, the contact of the uterine walls with 
the surface of the child has occasionally the effect of rousing the organ 
to action of the most violent and uncontrollable kind, although the parts 
may as yet be but imperfectly prepared for the stage of expulsion. 
Emotional causes of various kinds may also have a similar effect in pro- 
ducing contractions of such energy as to bring the labor to a termination 
with unexpected rapidity. In some cases, the operation of these causes 
is obviously beneficial, and the mere threat of operative interference, or 
the production of the forceps, will sometimes have the effect of rousing 
the flagging energy of the expulsive forces, and bringing matters to a 
termination before operative measures have been resorted to. Scarlatina, 
relapsing fever, and other acute febrile disorders have, in some instances, 
a precisely similar effect. 

In another class of cases, the rapidity of the labor seems to be due, 
less to the violence of the pains than to the deficiency of the resistance 
to the passage of the child through the parturient canal. In the case of 



588 THE PUERPERAL STATE. 

a pelvis of unusual size, this may take place, even although the pains are 
in no way beyond the average ; and, of course, if such an anatomical 
condition as this is combined with violent uterine action, the rapidity of 
the delivery may be such that only a few minutes intervene between the 
preliminary pains and the termination of labor. If the head is smaller 
or more yielding than usual, or the soft parts more than ordinarily dilat- 
able, these conditions will also contribute to a similar result. 

The dangers attendant upon precipitate labor are various. The ex- 
treme violence of the contraction may cause rupture of the uterus ; or 
the rapid passage of the child may cause laceration of the cervix, vagina, 
or perineum, and the more remote dangers to which these accidents give 
rise. In other cases, the uncontrollable violence of the expulsive action 
of the voluntary muscles (which in such a case become virtually involun- 
tary) may force the air into the cellular tissue, and cause emphysema of 
the face and neck. The sudden emptying of the uterus may be followed 
by a period of complete relaxation, so that all such cases are known to 
be peculiarly liable to postpartum hemorrhage. Rupture of the mem- 
branes only makes matters worse, and the direct pressure to which, in 
such cases, the child is subjected, exposes it also to no inconsiderable 
risk. 

Another danger to the child arises from the risk of delivery taking 
place when the woman is in the erect posture, when it may be seriously 
injured by being dashed upon the floor. The rupture of the cord, which 
would probably occur under such circumstances, is not, as some have 
supposed, an important source of danger, seeing that laceration of the 
vessels, which must under such circumstances take place, is in itself a 
tolerable barrier to hemorrhage. It has been observed, incases in which 
the resistance was much less than the expulsive force, that the uterus, in 
its undilated condition, has been forced down upon the perineum, and has 
even protruded externally before the os had sufficiently yielded to permit 
of the passage of the child. 

The Treatment of precipitate labor consists in adopting such measures 
as are available for moderating the violence of the uterine action. As 
a considerable number of cases are associated with some intestinal de- 
rangement, it is proper, in the first instance, to wash out the bowels by 
a simple injection of tepid water, the soothing effect of which will some- 
times become at once apparent. But if, as is more likely, the turbulence 
of the uterine action still continues, nothing is so likely to produce a 
decided effect as opium, given in the form of a suppository of one of the 
salts of morphia. This is better than the exhibition of any of the pre- 
parations of the drug by the mouth, more especially if there is a ten- 
dency to irritability of the stomach. The other sedatives have a similar, 
although less certain, effect ; and, in many cases, the result of chloroform 
inhalation is wonderfully to moderate the uterine action. 

A knowledge of the physiology of the expulsive forces will instinctively 
guide us to such management of the case as may obviate, as far as pos- 
sible, any voluntary action. Everything, therefore, which the woman 
might seize, or anything against which she could press her feet, should 
be carefully removed, while the action of the pain should be watched, 
and the woman encouraged to cry out lustily rather than to fix the glot- 



TREATMENT. 589 

tis. Such modes of treatment as we have shown to be useful in inertia 
should here be scrupulously avoided, and a directly contrary plan adopted. 
We should carefully avoid, therefore, digital examinations beyond what 
may be considered absolutely necessary, and protect the patient from all 
sources of mental emotion or physical excitement, and from any other 
cause which experience has proved to exercise a decided influence upon 
the uterine fibre. On no account should the w^oman be allowed to assume 
or maintain the erect posture, which is well known to act as a fresh in- 
centive to uterine action by allowing the child to gravitate downwards 
and press against the os and cervix. Although, theoretically, we might 
naturally suppose that the ordinary abdominal bandage would rather 
encourage than abate uterine action, it has been found that it some- 
times has a soothing efl"ect, adding to the comfort of the patient, and in 
some degree relieving her suffering. Should this expedient be tried, it 
will be well so to adjust the bandage as to support the womb by pressure 
applied chiefly between the lumbar and hypogastric regions. When 
procidentia is threatened, it may be necessary to support the uterus by 
means of a bandage applied externally, and so adjusted as to press 
against the vulva. When the lower segment actually protrudes, a hole 
should be made in the bandage so as to aid the longitudinal fibres of the 
uterus in mechanically overcoming the resistance of the circular fibres 
and tissues of the os. In this way, Naegele has operated successfully, 
allowing the child to be born actually through the aperture in the sup- 
porting bandage. 

In cases of violent and precipitate labor, the fearful exertion to which 
the patient is impelled may culminate in an epileptic seizure, or even in 
apoplexy. In some cases, the suffering is so great and so continuous, 
and the woman is worked up into such a state of frenzied excitement, 
that, at the moment of dehvery, she is actually unconscious of what she 
does. It is in consideration of this that the Continental codes look with 
leniency upon child murder perpetrated under such circumstances ; and, 
probably, even in our own country, if such facts were substantiated, the 
law would take a similarly lenient view, although it is not set forth in 
the statute-book. Another question in medical jurisprudence, and which 
may have an important bearing in cases of suspected infanticide, is the 
likelihood of the mere rapidity of the birth being the cause of death of 
the child, as cases are recorded in which children have been born while 
the woman was in the erect posture^ or even when she was at stool. It 
would appear, also, that sometimes, owing possibly to the great cerebral 
excitement, there is a greater tendency to the occurrence of puerperal 
mania, in women in whom the symptoms during labor have been of the 
nature of those above described. 



>90 THE PUERPERAL STATE, 



CHAPTEE XXXyill. 

THE PUERPERAL STATE: LACTATION. 

Management of the Puerperal State. — The Lochia : Nature and Source of. — After 
Pains: Treatment of . — The Lacteal Secretion : Milk Fever : Colostrum: The 
Child to he put to the Breast at Fixed Intervals: Agalactia: Galactorrhcea ; 
Two varieties of. — Management of Lactation : Effects of Over-Feeding. — Dura- 
tion of Lactation. — Effects of Menstruation and Pregnancy upon Lactation. — 
Disorders of Lactation. — Inflammation and Abscess of the Mamma: Effects 
of: Treatment. — Excoriation and Fissure of the Nipp)les : Prevention of: 
Treatment of. 

The management of labor, up to the stage when the accoucheur is able 
to leave his patient after her delivery, has already been described in a 
previous chapter. We now propose, however, to consider, somewhat more 
in detail, the treatment of the woman during the puerperal state, — while 
she is under the influence of conditions which, although strictly physio- 
logical, may very readily become morbid. The condition of the woman 
during the- period immediately succeeding the termination of labor is one 
of delightful calm and repose, which offers a remarkable contrast to the 
excitement and frenzy of the concluding stage of the process. The fall- 
ing of the pulse shows the subsidence of a turbulent circulation, and is 
due, in some degree, to a modified shock. When labor has been easy, 
and of moderate duration, there are no symptoms of shock ; but in other 
cases, and in proportion to the violence and duration of the process, the 
patient show^s symptoms, more or less distinct, of debility, and the shock 
to the nervous system manifests itself further by intolerance of light and 
sound, and other symptoms of temporary exhaustion. Perfect quiet, and, 
above all things, refreshing sleep, will speedily rouse the woman from 
the condition into which she has fallen ; and so important, indeed, is the 
latter point, that many experienced practitioners were in the habit of 
giving an opiate, as a matter of routine, shortly after delivery. In or- 
dinary cases, however, opium is unnecessary ; but, when there is shock 
and marked exhaustion, a moderate dose of the Liquor Opii Sedativus 
may frequently be given with advantage. 

The old method of treatment by starvation during the first few days, — 
when the diet was confined to tea, water-gruel, or arrow-root, — finds few, 
if any, supporters at the present time. Nothing, indeed, could be more 
irrational than such treatment, or more likely to retard recovery and dis- 
courage the lacteal secretion ; so that it will be quite proper, after the 
first day at least, in the great majority of instances in which the patient 
has had some sleep, to give chicken-soup, or beef-tea, in addition to the 



THE LOCHIA. 591 

dry toast, gruel, arrowroot, and sago, which are properly given at this 
stage, as being substances easy of digestion. 

In the course of his subsequent visits, the accoucheur should see that 
the bandage is properly managed, and tightened from day to day ; and 
it is well, by firm and equable pressure, exercised over the hypogastric 
region, — which has often the effect of dislodging clots, — to be assured ot 
the satisfactory state of the uterus as regards contraction. One of the 
first points to which he addresses his inquiries is with reference to the 
function of the bladder, which is sometimes resumed with difficulty. 
Laving with warm water will usually be all that is required to excite the 
bladder to contraction ; but, in some cases in which the labor has been 
difficult, the viscus is actually paralyzed, so as to require the use of the 
catheter, which may have to be repeated for several days. 

If the bowels have been freely moved, as they should always be, shortly 
before delivery, we need pay no attention whatever to that function until 
at least forty-eight hours have elapsed. Torpor of the bowels is, after 
labor, an almost invariable condition, which is probably due, as Dr. Tyler 
Smith says, to " the exhaustion induced by labor in all the organs under 
the influence of the spinal cord." Under the ordinary conditions of the 
puerperal state, it is, therefore, necessary to give some laxative medi- 
cine, — of which class of remedies castor oil is undoubtedly the best. 
Other laxatives may, no doubt, act with equal efficiency ; but, as a rule, 
and especially in the form of a pill, they are not to be depended upon. 
It is somewhat remarkable that, sluggish as the bowels are, they respond 
very readily to the action of laxatives, even in the case of those wdio are 
habitually costive. It will therefore rarely be found necessary to pre-^ 
scribe more than a dessert-spoonful of castor oil, which may be given 
with lemon juice early in the morning. On several occasions we have 
seen an ordinary dose of half-an-ounce followed by such violent action as 
to require opiates to restrain the purging. 

The Lochia. — While the placenta, during the third stage of labor, is 
being separated and expelled, a considerable a,mount of hemorrhage 
naturally takes place, and, after the completion of the process, blood 
continues to ooze from the ruptured and partially closed vessels on the 
inner surface of the womb. Efficient and rhythmical contraction of the 
uterus prevents the flow from becoming so profuse as to be dangerous ; 
but still, a certain amount of discharge goes on for a time ; and, indeed, 
it is well known that the maintenance of this discharge, for a certain 
time after delivery, is, to some extent, a guarantee of the favorable pro- 
gress of the case ; while, on the other hand, its premature arrestment is 
an almost invariable accompaniment of the more serious puerperal dis- 
orders, and is therefore always looked upon with more or less of appre- 
hension. In order to understand the true nature of the lochial discharge, 
it is necessary to consider for a moment the anatomical condition of the 
parts from whence it springs. 

That part of the uterus from which the placenta has been separated 
was compared by Harvey to the stump of a limb after amputation ; but, 
although the simile has been frequently repeated, physiologists are well 
aware that it is only to a limited extent correct. The vessels, no doubt, 
are torn across in the course of the separation of the placenta, but, with 



592 THE PUERPERAL STATE. 

tins exception, there is no real breach of tissue, as nature has for many 
weeks been preparing for the process of separation. At birth, the 
inter-utero-placental tissue divides into two layers as was formerly ex- 
plained, one of these remaining adherent to the uterine wall, along with 
portions of the decidua serotina. If the womb be examined shortly after 
delivery, that part of it to which the placenta was attached will be ob- 
served to be thicker than the other portions, and projecting somewhat 
into the cavity of the uterus. Upon this surface, which is rugged and 
unequal, small clots, projecting from the orifices of the closed vessels, 
and so contributing to their efficient closure, are observed, along with 
shreds of membrane ; and, over the whole inner surface of the cavity of 
the organ, remains of the decidua vera or of the subjacent textures from 
which it has been stripped are clearly to be made out. The discharge, 
then, which constitutes the lochia is, in the first instance, composed of 
almost pure blood. After this, it is still sanguineous, but has been found 
by M. Robin to contain an unusually large proportion of white cor- 
puscles. As the discharge changes in character, the proportion of white 
corpuscles becomes higher and higher, and these are believed by the 
same authority to have their origin directly in the inner surface of the 
uterus. This increase in the number of white corpuscles usually becomes 
manifest after the second day, and is accompanied by a proportional 
diminution of the red corpuscles. The discharge gradually assumes a 
reddish gray, and then a greenish or yellowish hue, at which period 
there are scarcely any red corpuscles to be found. The white cells are, 
however, the predominating element, and some of them may now be 
observed to have become voluminous and full of fatty granules, having in 
fact assumed the characters which have gained for them the name of 
" granular globules." Along with these elements Avill be found frag- 
mentary traces of the decidua, and also pavement epithelium from the 
mucous membrane of the vagina. 

The lochial discharge has a peculiar odor, sometimes offensive in 
character, but at no time, if it follows a normal course, is there a purulent 
discharge, nor is the process really analogous to the suppuration which 
accompanies the reparative process of a healing stump. While the 
remains of the decidua are thus being separated, the small clots which 
plug the vessels, or are adherent to the surface, undergo a process of dis- 
integration, and are separated along with the other constituents of the 
lochia. The new mucous membrane, which, according to Robin, begins 
to form beneath the decidua as early as the fourth month, is distinct 
about the ninth day, when the columnar epithelial cells begin to be de- 
veloped. The surface then becomes smooth, and the discharge becomes 
colorless and finally ceases, these changes going on ijari jmssu with the 
process of fatty degeneration of the muscular fibres which has been pre- 
viously described. 

Care should be taken by the nurse to promote, while avoiding unneces- 
sary interference, the lochial discharge. A strict regard to cleanliness 
is the most important indication. The external parts are, with this view, 
to be sponged with a weak solution of carbolic acid or Condy's fluid, and 
the napkins changed as often as may be necessary ; and if the fetor is 
unusually great, or if the part have been lacerated, it is well to wash out 



AFTER-PAINS. 593 

the vagina daily, by a warm injection, containing either of the in- 
gredients above mentioned. The discharge is also promoted by the acts 
of defecation and micturition, and by any change of posture ; and it is a 
good practice, after the second day, if nothing should occur to contra- 
indicate such a procedure, to encourage the woman to make water on her 
knees, which permits of the escape of any portion of the fluid which may 
have become accumulated in the cavity of the vagina. 

After-Pains are the natural accompaniments of the contractions which 
usually take place after labor, having for their object the expulsion of 
any clots that may be contained within the cavity of the uterus, 
and probably the expulsion of the clots which seal the vascular orifices. 
These after-pains are trifling or altogether absent in primiparce, but are 
almost always present, in a greater or less degree, in women who have 
previously borne children, tip to a certain point, they have a decidedly 
salutary effect, and contribute to the favorable progress of the case ; but 
it not unfrequently happens, particularly in women who have had many 
children, that they are so severe as to cause much suffering and no little 
constitutional disturbance. Anything, in these cases, which tends to 
engender reflex uterine contraction will be pretty sure to aggravate the 
symptoms, so that vaginal examinations and irritation of the rectum and 
bladder should, as far as possible, be avoided or rectified. One of the 
most familiar causes of after-pains, so common as to have given rise to 
an aphorism among nurses, is the application of the child to the breast ; 
and the accoucheur should generally avail himself of this well-known 
fact to insure thorough and efficient uterine contraction. And we may 
here repeat what was stated on a previous occasion, that nothing tends 
so much to insure that the after-pains shall be moderate in degree, as 
firm pressure on the fundus, careful attention to the contraction of the 
uterus during and after the expulsion of the placenta, and the complete 
removal of all clots and shreds of membrane from the os and cervix. 

The after-pains usually commence soon after labor, and in bad cases 
they last for three or four days. In other cases, again, they are at first 
moderate, and, after some time, come on with great violence. If there 
be any suspicion of retained coagula, it will be proper to pass the finger 
into the vagina, and remove any clots which may be within reach. 
Should no such cause be discernible, and the pains still persist, the 
application of a warm poultice over the hypogaster, or a soothing 
injection into the vagina, will often suffice to allay the suffering, if not 
to cause perfect relief. In France, an ointment containing bella>donna 
has been extensively used, and no doubt may be productive of benefit, 
but the objections to the general use of this drug have already been 
stated. In some instances, the pains are distinctly neuralgic, or are 
associated with a rheumatic condition of the uterus ; and in these, 
as well as in all other cases in which the sufferings of the woman go 
beyond a certain point, and especially when they prevent sleep, opium 
may be given without hesitation, either by the mouth or by enema. It 
is well, however, before giving opium in any form, to be sure that there 
is no irritation of the bowel, from over-distension or any other cause, as 
it will be proper to relieve that condition before having recourse to 
sedatives. Dr. Tyler Smith found benefit occasionally to result from 
38 



594 LACTATION. 

the application of an anodyne embrocation to the breasts. It must be 
clearly understood that after-pains, although due, in their usual form, to 
a physiological action, are, when severe, not to be neglected ; for, not 
only may the want of sleep and constitutional irritation lead to un- 
pleasant results, but the case, if abandoned to nature, may even pass 
into inflammatory disease, which, at this particular epoch, is, as we shall 
see, peculiarly disastrous in its effects. 

The Lacteal Secretion. — The enlargement of the breasts, which is so 
characteristic a sign of pregnancy, is usually accompanied, not only with 
increased development of the mammary glands, but also, during the 
last few months of gestation, with a secretion of more or less milk. 
The quantity is, however, small, and although it may, in some cases, be 
pressed out in jets from the nipple, there is no accumulation of the 
fluid in the ampullse of the galactophorous ducts. In most women, no 
marked alteration takes place until about the third day, when the secre- 
tion of the milk — properly so called — commences. At this time, there 
often is what has been described as a rush of milk to the breasts. The 
glands become considerably enlarged, and greatly more vascular, and the 
pulse very commonly rises a little, when the mother may complain of 
headache. A febrile condition has indeed been described by the older 
writers as a normal accompaniment of the establishment of the secretion, 
but the constitutional symptoms to which the local determination of blood 
at this time gives rise can scarcely with propriety be described as a 
fever. This is true, at least, in regard to all ordinary cases ; but it is 
by no means an unusual occurrence for the patient to be attacked with 
a rigor, which is generally slight, followed by heat of skin, rapid pulse, 
and headache — symptoms which are relieved by free perspiration and a 
copious secretion of milk. 

This is what is commonly known as Milk Fever, and is identical with 
what is otherwise described as ephemera or weed. Whatever the degree 
of fever may be, the state of the breasts requires prompt attention. One 
of the advantages of putting the child early to the breast is that it draws 
out the nipple, which may be small or flat ; and what is now very likely 
to occur, should this have been omitted, is a projection of the areola, 
which participates in the tumefaction of the rest of the gland, so that 
the nipple falls in, as it were, on a level with the skin, when it becomes a 
matter of some difficulty for the child to seize it. Putting the child to the 
breast is the natural and almost instinctive method which the Avoraan 
adopts for the relief of the painful distension which she experiences, 
but, as the child at first drinks but sparingly, it may be necessary for 
the nurse to relieve the gland by the use of the breast-pump or other- 
wise, aided by gentle frictions with olive or camphorated oil. These 
may be directed more especially to such portions of the gland as may 
show a tendency to induration or knotting, due in the first instance to 
local accumulations of milk, and subsequently, if neglected, to inflamma- 
tions of the surrounding tissues, which may proceed to abscess. It is 
always of importance to keep the breasts cool at this stage, and it may 
even be necessary to keep down the temperature by evaporating lotions 
when there is reason to apprehend the more violent action which is apt 
to culminate in abscess. No small amount of suffering arises in some 



COLOSTRUM. 595 

instances from the weight of the inflamed gland, which gives rise to 
dragging and aggravation of all the symptoms. This condition can 
fortunately be greatly relieved by the simple expedient of suspending 
the breast by means of a handkerchief slung round the neck. 

It is a very usual thing for nurses to put the child frequently to the 
breast, with the view of relieving such symptoms as are here described. 
This, however, should always be done with caution, and in view of the 
whole circumstances of the case. For it must be remembered that this 
eifect of the contact of the child is not only to empty the breasts, but 
also to stimulate them to increased secretion, and if this latter effect — 
as it well may be — is in excess of the former, the treatment is obviously 
injudicious, and is likely either to precipitate the direct effects of in- 
flammation, or to induce an excessive secretion of milk, which in most 
women has a serious effect upon the general health. Besides, the too 
frequent contact of the child is apt to cause certain painful affections of 
the nipple to which we shall afterwards advert, and is by no means free 
from risk to the child itself. 

The Colostrum^ or milk first secreted, is somewhat irritant, and thus 
has a satisfactory effect in removing, by its laxative action, what remains 
of meconium in the bowels, and in preparing the mucous membrane of 
the alimentary canal for its functions of assimilation and excretion ; but 
the too frequent ingestion of this, or even of perfectly developed milk, 
is apt to keep up a continuous digestive action in the stomach, and give 
that viscus no time to rest ; and, even when the child sucks vigorously, 
the repeated over-distension of the stomach only results in rejection 
again and again of what has been swallowed. The mother ought, if 
possible, on each occasion, to put the child to both breasts, as the 
emptying of one, and leaving the other in a state of complete disten- 
sion, as is sometimes done, is not likely to contribute much to her 
comfort. It is always better partly to empty both breasts than wholly 
to empty one. 

It is, therefore, of great importance that the mother should be warned 
from the first not to put the child too frequently to the breast. If the 
child sleeps by her side, this is the ready method of cure for restless- 
ness and screaming fits, and the child is often allowed to fall asleep with 
the nipple in its mouth ; but, if it once contracts this habit, it may be- 
come impossible for it to be put to sleep in any other position, while it 
drinks at intervals without the consciousness of the mother. This, of 
course, an experienced nurse will never permit, but it is a matter of 
greater difficulty to determine what is sufficient nourishment for an 
infant, and at what intervals it should be given. This would, perhaps, 
fall more properly to be considered in the following chapter, but, as it 
involves the interests of the mother as well as those of the child, we 
may here observe that it is of much importance to accustom the child 
from the first to drink at regular intervals. These, to begin with, may 
be every two hours, or if the child be premature or feeble, and on 
that account able only to take a small quantity of nourishment at a time, 
it Avill be necessary to put it to the breast at shorter intervals. But the 
object of the mother should always be to increase the interval until, 
after the second or third week, the infant becomes accustomed to take 



596 LACTATION. 

its natural nourishment every three or even four hours. This enables 
the mother to have her natural rest, and allows of the steady and satis- 
factory filling of the breasts against the stated periods. 

It often happens, in women too who have an abundant supply of milk, 
that much disappointment results from the frequent escape, and con- 
sequent waste of the secretion. A certain amount of overflow, just at 
the commencement, when the breasts are tumid and distended, is so far 
beneficial ; but when this goes on — independent, it may be, of the amount 
of the secretion — it comes to be a serious matter, and may give rise to 
no little perplexity and annoyance. The milk which thus runs from the 
breasts may keep the woman in a constant state of moisture and discom- 
fort, and although it is possible to collect the fluid discharged in small 
vessels which are used for the purpose, and even to give it to the child 
by a spoon, this is ahvays an unfortunate occurrence. It is certain that, 
by careful attention to the period at which the child should be put to the 
breast, on the one hand guarding against over-distension, and on the 
other avoiding frequent and irregular applications of the child, much 
may be done to prevent this loss. In some cases, when the glands reach 
a certain stage of distension, the woman is conscious of a feeling of mo- 
mentary discomfort, and then of involuntary contraction, immediately 
after which the greater part of the accumulated secretion is expelled, 
not unfrequently in jets. In other instances, this spasmodic contraction 
is excited by the contact of the child, when both breasts are simultane- 
ously the seat of contraction, so that while the infant is half choked 
with the milk of one breast, that of the other is expelled in jets as before. 
In another class of cases, the application of the child is attended with 
acute pain in the breast of a neuralgic character, sometimes, indeed, so 
severe as to cause the woman to cease nursing. Emollient and sedative 
applications, such as belladonna, have been employed with the view of 
soothing this painful affection ; but, in some cases, it defies both these 
and internal remedies, and ultimately compels the woman to yield. 

Every conceivable shade of difference is found to exist between dif- 
ferent women, even of the same constitution and temperament, in the 
quantity of the lacteal secretion, and also in regard to its quality. In 
one case, we find a delicate, fragile woman, who may even be the subject 
of constitutional disease, but is, nevertheless, over-burthened with milk; 
while, in the next which comes under our notice, a young, robust, and 
vigorous woman, who has never had an hour's illness, fails completely in 
so far as the lacteal function is concerned. We do not, of course, mean 
to imply that these are common cases, but they are certainly not such as 
would cause the experienced practitioner a moment's astonishment. The 
commencement of laction may, in like manner, be ushered in with all the 
usual symptoms, and be at first abundant only to fail in a few days ; 
while, in another, the secretion is ultimately satisfactorily established 
after a period of doubt and difficulty. Although, therefore, we know 
that strong and healthy women are more likely to prove good nurses, we 
can never be certain, until a week, or even longer, has passed, how the 
case, in this respect, is likely to turn out. There is no doubt that, 
although there are other conditions which influence the secretion of the 
milk, the state of the uterus, and the natural sequence of events of which 



GALACTORRHCEA. ' 597 

it is the seat, exercise an important influence, owing to the well-known 
sympathy which subsists between the organs. 

In the condition which has been termed Agalactia^ the secretion is 
either altogether arrested, or is manifestly insufficient in quantity for the 
nourishment of the infant. Among the most frequent causes which lead 
to this condition are acute diseases, more especially if they immediately 
succeed the period of delivery. It is, in fact, one of the most common 
symptoms of those febrile diseases which sometimes supervene on the 
puerperal state, to the alarm of the attendants, and not seldom with the 
most disastrous results ; and the failure of the secretion is always looked 
upon as of more serious import, if it is accompanied by the premature 
cessation of the lochia. But, independent of any other marked or serious 
symptom, there is sometimes a simple failure of the discharge, w^here it 
is difficult or impossible to recognize the cause. 

We are not, however, to suppose that such failure is conclusive evi- 
dence of permanent incapacity, on the part of the woman, to discharge 
this natural function. If due to a febrile condition of moderate duration, 
the discharge will often reappear with the abatement of the pyrexial 
symptom.s ; so that, by feeding the infant artificially for a time, we may 
wait until we see whether or not the function will be re-established. This 
will be furthered by the application of warm fomentations to the breasts, 
and of late years the leaves of the castor oil plant have been extensively 
used as a local application, with the view of increasing or exciting the 
secretion. For this purpose the leaves are to be boiled in a small quan- 
tity of water, and are to be applied along with the water in which they 
have been infused, in the form of a fomentation. 

The quantity of the lacteal secretion is, under no circumstances, to be 
accepted as a criterion of its quality. The eye enables us, in some 
measure, to judge of the abundance of the corpuscular elements upon 
which the nutritive value of the secretion mainly depends. This may, 
however, be more accurately ascertained by means of a lactometer, or 
by the use of the microscope ; but it is to be remembered that the 
richest milk is by no means that which is necessarily best suited for the 
child. 

G-alactorrhoea, or a too abundant secretion of milk, has been described 
under two forms, involving very different conditions and management. 
In the one, the quantity alone is abnormal, the nutritive value of the 
secretion being unaffected, so that our object in treatment would naturally 
be to guard against such an unnecessary drain upon the mother, as might 
be expected ultimately to compromise her general health. In this variety, 
the effect produced upon the child may be perfectly satisfactory, the only 
inconvenience, in many cases, being from the rapidity and abundance of 
the flow from the reservoirs within the gland, so that the mouth of the 
child fills much more rapidly than it can swallow, to its great and obvious 
discomfort. The treatment of such a case should consist mainly, if not 
entirely, in regulation of the diet, watching narrowly the while what 
effect is being produced upon the health of the mother, and adopting such 
means as may seem necessary for its rectification, by the partial arrest- 
ment of the discharge, or otherwise. 

In the other variety of galactorrhoea, the conditions are widely dif- 



598 LACTATION. 

ferent. Here, too, there is abnormal abundance ; but, in addition, we 
find that the increase in bulk depends mainly or entirely upon an aug- 
mentation of the watery parts of the fluid. Not only is this a state of 
matters extremely unfavorable to the infant, but it is often observed to 
exercise an unsatisfactory influence upon the mother. Indeed, in extreme 
cases, so serious and so obvious are the effects thus produced, that the 
expression " Mammary Diabetes" has been suggested by the rapid emacia- 
tion which occasionally supervenes. Along Avith great feebleness, there 
unfortunately exists sometimes, in these cases, complete loss of appetite, 
so that it is almost impossible to combat the symptoms by what we might 
judge to be appropriate diet. When the anorexia is less marked, the 
digestive functions may be disturbed — gastric and intestinal disorders 
being of frequent occurrence, taking the form, it may be, either of 
vomiting with heartburn and pyrosis, or of obstinate diarrhoea with 
flatulent distension and tenesmus. In those cases, ordinary remedies 
may prove of little avail, and after a few weeks of struggle it will become 
evident that no alternative remains except to wean the child, and take 
such other measures as may permanently arrest the secretion. This 
affection is believed to be particularly dangerous to those who have any 
phthisical tendency. 

From what has been said, it Avill be sufficiently obvious that the 
Management of Lactation must not unfrequently be a prominent part of 
the duties of the accoucheur. Nothing, in this respect, is more impor- 
tant than that the diet of a nursing woman should be, in quantity and in 
quality, such as is most likely to conduce to the health of the child, as 
well as to her own. In the case of a perfectly healthy woman, but little 
attention to regimen is required, — nothing further being necessary, in 
such instances, than that the woman should avoid any imprudence in diet, 
while in other respects she need make no change in her ordinary habits. 
The pregnant state, however, and the subsequent exhaustion which attends 
the process of parturition, very generally leave the woman in a condition 
which manifestly requires generous treatment, in order that the health 
may be re-established, while provision is made for the special drain on 
the system which the function of lactation involves. Among the higher 
classes, where luxurious habits tend to the diminution of constitutional 
vigor, and among the inhabitants of towns, the necessity for such treat- 
ment is much more prominently marked than in country districts, where 
a life of physical exertion, spent, to a great extent, in the open air, im- 
plies hygienic conditions which are the very opposite of those which we 
observe in the other case. In ordinary practice, however, the necessity 
for a liberal dietary is so universally recognized that there is a danger 
of falling into a routine practice in this respect, the result of which will, 
undoubtedly, in some cases, be the reverse of beneficial. 

As the result of some experience and close observation, we are con- 
vinced that indiscriminate over-feeding and stimulation of nursing women 
is a more frequent cause of the disorders of early infancy than is usually 
supposed. Nurses and mothers can readily understand how a thin and 
watery milk should fail to nourish the child, but it is by no means so 
easy to convince them that a specimen rich in nutritious elements may 
possibly be, from its very richness, the cause why an infant does not 



MANAGEMENT OF LACTATION. 599 

thrive. We have again and again seen cases of obstinate diarrhoea, with 
or without vomiting and other symptoms of gastro-intestinal derangement, 
which could only be attributed to this cause. Drugs are of no avail: 
the appearance of the mother maybe sach as to prevent even a suspicion 
of any fault on her side, and yet strict inquiry as to what she eats and 
drinks often points clearly to the simple and only proper treatment. It 
is to the use of stimulants that the attention in these cases be more par- 
ticularly directed ; for we often find that women are encouraged without 
any reference whatever to their general health or the state of the milk, 
to take considerable quantity of ale or stout, or of the stronger wines. 
Diminishing the quantities of these stimulants, and in some cases abso- 
lutely forbidding their use, will certainly, in many instances, be followed 
by a marked and immediate amelioration in the symptoms. But, even 
when stimulants are not admitted into the dietary, the cause may still be 
discovered in the habitual use of food which is too stimulating in its 
character, or which is taken in too great quantity. 

An interesting series of observations, bearing directly on this subject, 
have been deduced from analyses conducted by M. P^ligot, with the view 
of ascertaining the nutritive value of the lacteal secretion at various 
epochs. From these analyses it would appear that the longer the milk 
remains in the breast, the thinner and more aqueous does it become. It 
has been clearly established, further, that the milk which first flows from 
a distended breast — -this being the portion soonest secreted — is compara- 
tively watery, and that the quality of the milk becomes richer as the 
gland is progressively emptied. Hence a very obvious indication of 
treatment. When, for example, the child seems to be suffering from too 
rich milk, and there is reason to suppose that it is put too frequently to 
the breast, before the gland has time to fill, it may suffice to extend the 
period between the repasts, which, by giving the gland time to fill, also 
insures that the child obtains a less rich milk, and one more suited to its 
digestive capabilities. And we believe that the same facts may possibly 
be turned to account in the treatment of the opposite class of cases, 
where the secretion is too watery, and yet abundant, by partially empty- 
ing the breast before the child is put to it, so that, the more watery por- 
tion of the milk being removed, the child obtams the more nutritious 
residue. 

The duration of lactation varies very considerably. It may cease 
quite unexpectedly, a few weeks, or even days, after the secretion has 
been established, or it may last for years. Between these two extremes 
the range is obviously great; but, as a rule, in cases in which the 
whole circumstances are perfectly normal, the average duration may be 
set down as from twelve to fifteen months. This is, of course, supposing 
that the woman goes on nursing, and that nothing is done with the view 
of interrupting the function. The influence wliich is produced upon lac- 
tation by the menstrual function, is a subject in regard to which very 
vague ideas are sometimes entertained. As a rule, a woman does not 
menstruate while she continues to nurse, so that no disturbing influence 
from this source normally exists. In a very considerable number of 
instances, however, she menstruates after five or six months; and, in a 
small proportion of cases, the menstrual function is regularly discharged 



600 LACTATION. 

during the whole period that she gives suck. Much discussion has taken 
place as to the influence which the constitutional disturbance inseparable 
from the menstrual molimen exercises on the process of lactation ; and 
the question is often put to the medical attendant, whether the appear- 
ance of the catamenia is a sufficient reason for ceasing to nurse. It is 
beyond doubt that, in a large number (probably the majority) of cases 
in which menstruation occurs during lactation, no perceptible eifect is 
produced upon the child. It is equally true, however, that marked dis- 
turbance of the one function attends the premature establishment of the 
other, as is evidenced by the most delicate of all tests, — disturbance of 
the functions of the child, which in some cases is very marked, and 
recurs at successive menstrual epochs. We must not, therefore, in reply- 
ing to the question stated above, rashly assume, either that menstruation 
forbids nursing, or that it is to be disregarded. The truth lies between 
the two, and the solution of the question is to be found in a careful ob- 
servation of the effects which are produced on the mother and child, 
upon which alone a definite opinion can be formed. 

It sometimes happens that a woman becomes pregnant while she is still 
nursing, although the rule is that, during lactation, the generative func- 
tions are in abeyance, in so far, at least, as ovulation is concerned. In 
the exceptional instances referred to, it is not too much to suppose that, 
the whole generative force being diverted into a new channel, the nursing 
power must necessarily diminish ; and that this is actually the case, is the 
experience of all who have watched these phenomena most closely. Du- 
ring the first weeks of such pregnancy, the lactation may be but little 
disturbed, although there is good reason to believe that a failure in the 
amount of the milk, or an alteration in its quality, precedes, not unfre- 
quently, the period at which the woman becomes conscious of her state. 
On the whole, we do not hesitate to assert that the existence of preg- 
nancy is a clear indication that the woman should cease to nurse. 

The important function of lactation is liable to certain disorders, or 
disturbing influences, the management of which comes necessarily under 
the duties of the medical attendant. The most familiar of these is, un- 
doubtedly. Inflammation of the Mamma. From whatever cause the in- 
flammation may spring, the condition of the gland during the puerperal 
state manifestly is such as to favor the extension of inflammatory action 
which has arisen within the structure. Exposure to cold, the irritation 
of sore nipples, and constitutional disturbance of various kinds, are a few, 
among many, causes leading to local inflammation, which almost invari- 
ably attacks, in the first instance, the tubular structure of the gland. 
But a mere local affection of an external organ of limited extent, would 
probably be looked upon with little alarm, were it not for the fact that 
there here exists a peculiar liability to the formation of pus, resulting 
only too frequently in the formation of Mammary Abscess. 

It is said that women of a weakly, delicate, or scrofulous constitution 
are peculiarly liable to mammary abscess ; but, whether this be the case 
or not, there are many cases in which, in women of perfect health and 
vigorous constitution, this troublesome aff"ection quite unexpectedly mani- 
fests itself. There is, certainly, a great tendency to its reappearance in 
those who have suffered on a former occasion ; but, beyond this, there is 



MAMMARY ABSCESS. 601 

no marked predisposition upon which we can rely. The inflammation 
which precedes the formation of abscess is, if it be at all severe, ushered 
in by rigors, which are often of considerable severity. This is immedi- 
ately followed by fever, and very shortly by lancinating pain in the breast, 
which is increased on pressure. The site of the pain, usually circum- 
scribed, is further indicated by the presence of swelling and hardness, 
which, in favorable cases, become gradually resolved as the inflammation 
subsides, without the formation of pus. 

But, when abscess forms, the progress of the case is widely different. 
The inflammatory action, commencing, as we have seen, in the glandular 
structure, extends to the cellular tissue. The tumor, hard before, be- 
comes less circumscribed and softer, although no less painful. The gene- 
ral symptoms are unabated ; and, as the swelling still further increases, 
the cutaneous surface becomes hot and red, and ultimately oedematous, 
and glazed or shining. The latter symptoms indicate the formation of 
pus, the presence of which is still more clearly manifested by the feeling 
of fluctuation, which becomes more and more distinct as the cavity en- 
larges, and the pus approaches the surface. With the formation of mat- 
ter, there may be a renewal of the rigors, and there is generally painful 
throbbing and exacerbation of the fever. Finally, the cutaneous tissues 
yield, and the abscess bursts, discharging its contents to the great relief 
of the patient. Unfortunately, however, her troubles do not always cease 
here ; for, under the influence of a protracted drain on the system, she 
may be reduced to a condition of deplorable weakness, which may be 
aggravated by obstinate gastric or intestinal derangement, or by profuse 
night sweats. The cases which are, in the first instance, the most severe 
are not necessarily those which ultimately produce the most serious eff'ect 
upon the patient. It is true that the sj^mptoms are, at first, in propor- 
tion to the violence of the inflammation and the extent of the abscess. 
But, on the other hand, the violence of the attack is often, under such 
circumstances, apparently expended ; and, unless the discharge is abnor- 
mally protracted, the gland may gradually resume its healthy condition 
and normal function, while the constitutional symptoms rapidly disappear. 

In another class of cases, the symptoms at the outset are comparatively 
moderate, and the abscess correspondingly small. \Yhen the latter dis- 
charges itself, or is relieved by operation, the cavity contracts, and we 
imagine that the case is at end. But, ere long, the former symptoms 
re-appear, a second abscess forms, runs its course, and discharges its con- 
tents as before ; and, in some cases, a succession of such local inflamma- 
tions, individually of limited extent, may produce, collectively, such effects 
as more seriously to influence the health than a case which may at first 
have excited more apprehension in our minds. In those cases of repeated 
small abscesses, there is often extensive induration, which may affect the 
whole, or the greater part of the gland, especially that part of it imme- 
diately surrounding the nipple. 

The result of severe inflammation of the mamma, whether the abscess 
be single or multiple, usually is to destroy the nursing function of the 
gland. It is not that the secerning function of the gland is necessarily, 
or even generally, arrested;- but rather that the application of the child 
is attended with such pain and irritation, that it is at once impossible and 



602 LACTATION. 

undesirable. If the matter has been allowed to make its way to the sur- 
face, it often happens that a certain amount of sloughing occurs of the 
tissues surrounding, and immediately subjacent to, the orifice. By the 
same process, the continuity of the galactophorous tabes is also occasion- 
ally destroyed, and, as a consequence, a lacteal fistula is established. 
The continued secretion of milk in the unafi'ected portions of the gland 
is sometimes a serious obstacle, in this and other ways, to the satisfac- 
tory issue of the case ; so that it is proper, in many instances, by friction 
or the external application of belladonna, to do what we can to arrest 
permanently the function of the mamma on the affected side. It some- 
times happens that, by sympathy or otherwise, the other gland becomes 
similarly affected by inflammation and abscess, which, of course, makes 
the case a much more serious one. 

The treatment of inflammation of the mamma is thus, it need scarcely 
be observed, a matter of the highest importance. The initiatory pheno- 
mena of inflammation are to be combated by a careful management of 
the secretion, which should not be permitted to accumulate within the 
gland. This is, however, a matter of considerable difficulty ; for, while 
the application of the child, or the breast-pump, is often productive of 
irritation, rubbing of the breasts, which is the other alternative, is apt 
to increase it also. Cold or evaporating lotions are not to be depended 
upon ; so that we are often obliged at once to have recourse to leeches, 
fomentations, and poultices, just as we would in the case of the inflam- 
mation of any other gland. 

Should all our endeavors fail — as, unfortunately, they often will do — 
to arrest the inflammation, the earliest indications of the formation of pus 
are to be earnestly looked for. So soon as fluctuation can be detected, 
however faintly, the case may, we believe, often be cut short by early 
puncture, by means of an exploratory trocar or needle, which by giving 
vent even to a few drops of pus, relieves tension, and often, apparently, 
arrests the course of the disease. Where fluctuation is already distinct, 
and near the surface, free incision should be practised in the most de- 
pending part, making the opening — in order to avoid the lacteal tubes — 
in a direction radiating from the nipple, while the usual antiseptic pre- 
cautions are employed, as in the other surgical affections of a similar 
character. In some instances where the abscess is large, a drainage tube 
may be usefully employed. Both before and after the operation, great 
comfort is afforded to the woman by suspending the breast, by means of 
a handkerchief tied round the neck. In the case of a large abscess, the 
contraction of the cavity may be promoted by the application, externally, 
of broad strips of sticking-plaster, so adjusted as to contract the cavity 
Avithin which the matter lies. In other respects, the affection is to be 
treated as an ordinary surgical lesion, while the general health must, of 
course, be carefully attended to. Whenever much trouble is encountered 
in the treatment of mammary abscess, we should not delay in ordering 
the removal of the child from the breast. 

[The treatment of mammary inflammation and abscess is a subject 
of great practical importance, and one about which the young prac- 
titioner cannot be too thoroughly informed. It is unfortunately one in 
regard to which the directions of text-books are too often vague and 
indefinite. 



MAMMARY ABSCESS. 603 

For a number of years the editor, in his clinical lectures at the Phila- 
delphia Hospital, taught the large classes of students to give personal 
attention to the condition of the breasts in every parturient woman under 
their care. Many nurses appear to think it their especial function to 
attend to these organs, and they have been frequently known to resent 
any interrogations of the accoucheur in regard to the breasts, as an un- 
warrantable interference with their duties, while the young physician is 
too apt to accept their statements, and to be restrained from making a per- 
sonal examination of the glands from motives of delicacy. As a conse- 
quence of this we have several times known mammary abscess to be dis- 
covered by the medical attendant too late to be aborted, or the conditions 
which give rise to it to escape his notice until too late to prevent these 
distressing results. We cannot therefore lay down a better practical rule 
for the guidance of the young obstetrician, than to make himself per- 
sonally acquainted with the state of the breasts of his puerperal patient 
each day until the danger of mastitis is past. If the nurse is trusted, 
and information is received secondhand, he will surely have to regret his 
negligence sooner or later. 

The treatment of inflammation of the breast varies with the condition 
of the patient and the stage of the disease. It may sometimes be aborted 
if treatment is commenced during the first twenty-four hours after the 
commencement of the disease. If the patient is vigorous, with high 
febrile reaction, and a full, strong pulse, we would not hesitate to 
administer a fever mixture containing ipecacuanha or even tartarized 
antimony. This may be safely given on the fourth or fifth day after 
confinement. The dose should be large enough to produce nausea, and 
diaphoresis, which will be followed by relief of pain, fall of temperature, 
and a diminution in the force and frequency of the pulse. At the same 
time the woman should take a saline cathartic. The general treatment 
of the subglandular variety does not difier materially from that of inflam- 
mation of the areolar tissue of the organ itself. 

In that form of inflammation in which the subcutaneous areolar tissue 
is involved, the local treatment is very important. The patient will 
sometimes be relieved by the application of leeches, but more frequently 
the local use of iodine and astringent solutions will be found to be sufli- 
cient. In order to be useful in aborting mammary inflammation, iodine 
must be applied early, before the end of the first twenty-four hours. Our 
own practice is to put it on freely, and then to cover the breasts with 
cloths wet in a strong solution of acetate of lead and opium. If the 
patient is debilitated and weak, as is too often the case, depressing febri- 
fuges are, of course, contraindicated. In these women a combination of 
neutral mixture and sweet spirits of nitre may be given with quinia in 
doses as large as the patient will bear, as recommended by Prof. Barker. 
Mr. Skey prefers dessert-spoonful doses of Huxham's tincture, but the 
alcohol in this preparation sometimes disagrees with the stomach. In 
both strong and debilitated patients narcotics may be demanded to relieve 
pain and procure sleep. 

There are two questions in relation to the treatment of this stage of 
the disease which demand a passing notice. Most nurses and even a 
number of physicians imagine that benefit will be derived from rubbing 



604 LACTATION. 

the breast under these circumstances. It is supposed that this favors 
the discharge of the milk. We know of no more irrational treatment, 
and it cannot be too strongly condemned. If an abscess was forming in 
the cellular tissue of the arm, thigh, or any other part of the body, any 
intelligent physician or surgeon would at once prescribe rest. In 
inflammation of the connective tissue of the breast, however, rubbing is 
sometimes advised as though the diseases of this organ were governed by 
laws different from those which control other parts of the body. 

The second matter is the supposed influence of the milk. There can 
be no doubt that the accumulation of this secretion in the glands leads 
to irritation and pain. When this is the case they should be emptied 
by sucking, performed either by the nurse or a puppy. If a breast- 
pump is employed it should be done with great care. We have known 
this instrument to cause an abscess many times, while we have very 
rarely known it prevent one. Dr. McOlintock, of Dublin, believes that 
bad consequences rarely follow the accumulation of milk in the breasts, 
and no inconsiderable experience has led the editor to conclude that there 
is much truth in this opinion. The profession is not even now freed from 
the erroneous pathological views of Puzos and his followers, in which the 
retention of the milk played a prominent part. The mammary gland, it 
seems, has been supposed to be an exception to all secreting organs in 
the body in the fact that retention of its secretion is followed by inflam- 
mation. This is not the case with the kidneys, liver, or salivary glands. 
It is true, how^ever, that the breasts differ from these organs, because 
their secretion is not constant, because they are called into functional 
activity more or less suddenly, and in a manner that predisposes the 
organs to irritation and inflammation. While, therefore, we wish to 
ascribe all due importance to the retention of the milk, and acknowledge 
that it may produce uneasiness and discomfort for the woman, we must 
protest against this being assigned a high place amongst the causes of 
mastitis, as well as against the alleged necessity of repeatedly and 
thoroughly emptying the organ in inflammation of the areolar tissue of 
the gland and that which is between it and the chest-walls. 

The treatment of the first stage of glandular inflammation of the breast 
is to be conducted on the same general principles which govern the 
management of the other varieties. In this form gentle frictions are 
sometimes useful during the early stages by dislodging the thickened 
secretion of the gland. The hand should be covered with sweet oil or a 
solution of camphor in sweet oil, and the breast rubbed from the circum- 
ference towards the nipple. Prof. Barker says that he has found local 
applications of belladonna useful in this form of the disease. We have 
repeatedly used the extract applied to the breast on a cloth, but have 
never felt willing to conclude that much benefit results from its use. It 
certainly relieves pain, but it is doubtful whether it exerts much influence 
in diminishing the lacteal secretion. Dr. McClintock believes that it 
does not, and in cases in which he applied the cere-cloth to one breast 
and belladonna to the other in the same woman, the results on the two 
sides did not differ materially. 

If the measures just described do not arrest the progress of the inflam- 
mation, it is the duty of the medical attendant to favor suppuration by 



MAMMARY ABSCESS. 605 

all the means at his command. It is important now to decide at what 
time the abscess should he opened. Most authors advise the early use 
of the lancet. The editor followed this advice for a number of years 
after commencing practice. He w^as often mortified and disappointed to 
find that after the discharge of the pus the process of repair did not go 
on at all rapidly. After having read Dr. McClintock's Clinical 3Ieinoirs 
on Diseases of Women, he concluded to try the plan of opening the ab- 
scess late, which that author recommends. The result of this practice 
has been in the highest degree satisfactory, and has led him to conclude 
that the popular idea that an abscess should " be ripe" before it is 
opened, is not entirely without foundation. The writer's practice is to 
watch the disease carefully during the suppurative stage to prevent bur- 
rowing of the pus, but not to interfere unless this occurs, until the pus 
has approached the surface and the abscess is almost ready to open 
spontaneously. 

It may be said by some, that under these circumstances it is not ne- 
cessary to use the bistoury at all. Clinical experience has disproved 
this. If left to open itself, sloughing of the skin and subcutaneous tissue 
may occur, leading to so much destruction of tissue that the recovery of 
the patient may be considerably delayed. The incised wound made by 
the knife preserves these tissues, while the evacuation of the abscess is 
followed by contraction of its cavity and rapid recovery of the patient. 

Subglandular abscesses are often exceptions to the rule that punctures 
should be made late. The pus in these is bound down between the large, 
tense gland in front, and the unyielding chest-walls behind. As a result, 
the patient suifers great pain, and yet it may be impossible to demon- 
strate the presence of pus by fluctuation. Under these circumstances the 
breast should be seized and pulled forwards, when a fine trocar or an 
aspirating needle may be inserted between the gland and the thoracic 
wall in order to determine whether suppuration has or has not occurred. 
If it has, an incision should be made beneath the most dependent part of 
the gland. 

If cure does not follow the discharge of the pus, the pressure by adhe- 
sive strips, as recommended by the author, should be tried. 

During this stage of the disease the strength of the^woman should be 
sustained by the use of good food and tonics. 

In certain cases, and especially in the subgl'indular variety, long fistu- 
lous tracts may follow an abscess. It is sometimes very difficult to heal 
these. To lay open the sinus it is necessary to cut through the whole 
thickness of the mammary gland, a procedure which is too serious to 
adopt. In a case of this kind, in which several fistulous sinuses followed 
an abscess between the gland and the chest-wall, we succeeded in effect- 
ing a cure by repeated injections of a solution of carbolic acid through a 
small trocar. In another instance a small piece of a stick of nitrate of 
silver was carried to the bottom of the sinus and left there. A cure fol- 
lowed. Many other remedies had been tried and had failed. Injections 
of iodine and of the sulphates of zinc and copper have been recommended 
under the same circumstances. Such sinuses can generally be readily 
cured if treated on ordinary surgical principles. — P.] 

Excoriation and Fissure of the Nipple are affections so common, and 



606 LACTATION. 

withal so troublesome and painful, that their treatment should be a mat- 
ter of interest to every careful and judicious practitioner. Although in 
themselves they are comparatively of little moment, they are of peculiar 
importance as causes of the more serious affections which we have just 
been considering. Much may, undoubtedly, be done in the w^ay of pre- 
vention. Women, among the higher classes especially, should be in- 
structed to lave the nipple, for many weeks before delivery, with some 
mild astringent or stimulant lotion, such as a weak solution of tannin in 
rose-water, or any dilute spirit. When, however, excoriation has already 
taken place, the nurse should be instructed to apply some very gentle 
astringent at first, — nothing being better than a strong infusion of tea. 
Failing this, the applications above recommended for prevention may be 
tried, or other similar medicaments — of which there is an endless variety — ■ 
may be adopted. Care must, however, be taken to avoid such substances 
as may be prejudicial to the child, — such as acetate of lead ; and in all 
cases the application should be washed off very gently before the infant 
is put to the breast. In the more obstinate cases, the following will be 
found an admirable substitute: — 

;^. Acid. Tannici .... gr. iij ; 

Glycerin ^ss ; 

Unguent. Cetacei, ad . • §,!• M. 

Fissures or chaps are even more troublesome than excoriation ; for, 
although they may at first be but trifling, every application of the child 
tends to tear them open, and undo the healing process of the interval. 
The above, or any similar ointment, will here also be found of great use, 
the best method of application being to introduce it into the chap by 
means of scraped lint. Should the margin of the fissure become callous, 
it may be necessary to apply freely the solid nitrate of silver. The 
nipple-guard, or shield, is, in all cases, useful in protecting the affected 
parts from the pressure of the dress ; and, when much pain is experi- 
enced in the act of suckling, the artificial nipple should be employed, 
which will protect the parts from the violence to which they are often 
subjected by the vigorous sucking of a healthy child. In some obstinate 
cases, the irritation is such that it may ultimately be found necessary to 
remove the child permanently from the breast, and to obtain the services 
of a hired nurse. 



THE NEWLY-BORN CHILD. 607 



CHAPTEE XXXIX. 

THE NEWLY-BORN CHILD. 

Management of the Cord. — Clothing. — Cleanliness. — Light and Air. — Colostrum: 
Improper Use of Laxatives. — 71ie Mother to Nurse if Possible. — Selection of 
Hired Nurses ; their Diet and Regimen. — Causes of Difficulty in Sucking. — 
Congenital Malformations. — The Excretory Functions. — Diarrhoea: Simple 
or ^'- Catarrhal^" and Lifammatory or ^^Dysenteric" Varieties: Treatment of 
Each. — Constipation: Management of. — Icterus Neonatorum. — Thrush. — 
Artificial Feeding: Substitutes for Breast Milk: Coiv^s Milk, Diluted and 
Sweetened : Nursing Bottles: Nurse to be procured if Child does not Thrice: 
Other Articles of Diet: Liebig's Food for Infants. — Weaning. — Dentition. 

The subject of this chapter has reference to certain points relative to 
the management of the infant after its birth, and the treatment of some 
of the more common ailments which are apt to attack it during the first 
weeks or months of its existence. 

So soon as the nurse has, after the termination of labor, attended to 
those matters of detail which are essential to the safety and comfort of 
the mother, her attention is naturally turned to the child, which is then 
to be washed and dressed. The first point to be looked to, after it has 
been thoroughly cleansed by soap and warm water, is the stump of the 
cord, which undergoes a process of putrefaction, and, ultimately, in the 
course of a few days, separates at the cutaneous margin of the umbilicus. 
The decomposition of the tissues of the cord takes the form rather of 
withering than of moist putrefaction ; but, before it drops off, there is 
generally more or less of the odor characteristic of the process which is 
going on. To. obviate this, it has long been the practice to wrap the 
cord in cotton or linen, passing the stump, in the first instance, through 
a hole which has been burnt in the cloth, so as to secure the antiseptic 
action of the charred margin. This, of course, is not essential, but is, 
undoubtedly, favorable to cleanliness ; and the dressing may be renewed 
at proper intervals, to be determined by the amount of moisture which 
makes its appearance, and which will depend, in a great measure, on the 
thickness of the cord. It occasionally happens, after the stump has 
dropped oft", that the navel remains gaping and raw, sometimes with 
ulceration, and even sloughing, of the margins, a condition which is 
always serious and sometimes fatal. For some time after the separation 
is complete, there remains a tendency, more or less marked, to the forma- 
tion of umbilical hernia. This is particularly noticeable in the case of 
children who are subject to screaming fits, and to the straining which 
accompanies them ; and is in all cases to be guarded against by the 
application over the umbilicus of a soft pad, formed by several folds of 



608 THE NEWLY-BORN CHILD. 

linen, which is retained in position by a broad bandage of flannel with 
which the abdomen of the child is swathed. .By increase in the thick- 
ness or otherwise, the pad may be so modified, in cases in which pro- 
trusion is threatened, as to retain the bowel within the abdominal cavity. 

[Dr. William Goodell prevents many of the accidents which may arise 
during the separation of the cord by the following modification of Dr. A. 
F. A. King's method of managing that organ. When the child is ready 
for removal. Dr. G. cuts the cord at the usual place, and then seizes it 
between the thumb and forefinger of the left hand, close to the umbilicus. 
Holding it firmly in this position, he then proceeds to " strip" it with the 
thumb and index finger of the right hand. 

By this means all of the blood and much of the gelatine of Wharton is 
removed. If there are accumulations of the latter in projections of the 
funis, these lobules are to be nicked with the scissors, and their contents 
squeezed out. The pressure near the umbilicus should now be tempo- 
rarily suspended, when the internal portions of the vessels collapse. 
The part is now subjected to a second stripping, after which, hemorrhage 
having ceased, it is tied in the usual manner. It is now left entirely 
free without any dressing whatever. The result is that it separates 
without any bad smell whatever, falling off " like a ripe fruit, without 
leaving a raw stump." 

Dr. Goodell states that since he has adopted this method of treating 
the cord in the Preston Retreat, the astringent lotions, which he formerly 
had frequent occasion to use, are never called for ; " but that since 
adopting this new method, out of more than two hundred infants, 
not a single one had had a pouting, angry-looking, or purulent um- 
bilicus ; nor had any one suffered from fungoid vegetations or umbilical 
hernia."— P.] 

The clothing of the child is in some measure to be regulated with 
reference to season and climate. In all cases, however, it is to be re- 
membered that birth almost necessarily involves a sudden and consider- 
able diminution of temperature. Any failure, therefore, in the vigor of 
the circulation, such as maybe anticipated in premature delivery, is very 
likely to be attended with a corresponding diminution in the temperature 
of the body, which not unfrequently involves great and sudden risk to the 
life of the child. The maintenance, therefore, at first, of an equable 
temperature is of the highest importance, and is universally recognized. 
On these grounds, flannel — which, as a bad conductor of heat, tends 
materially to sustain a steady temperature — is, to a great extent, em- 
ployed in the clothing of infants. It has also the advantage of absorb- 
ing the discharges to some extent, and thus preventing any irritation 
which may arise from their prolonged contact with the cutaneous surface. 
While the infant is thus wrapped in its swaddling clothes, care should be 
taken so to arrange them as to admit of free movement of the limbs from 
the first. It was at one time supposed that i\\Q head of the child should 
be protected as carefully as its trunk ; but the general practice now is 
rather to keep the head cool, so that, in this country, at least, it is the 
exception rather than the rule, to put even a light cap on the head of a 
child. Important as the maintenance of an equable temperature is in all 
cases, it is much more so when the infant is brought prematurely into 



ACTION OF THE BOWELS. G09 

the world — when it is necessary, in order to maintain the circulation, to 
swathe the limbs in cotton-wool, at least durinor the first few weeks after 
birth. In all cases, for the first few months, the heat of the trunk and 
lower limbs is further insured by the use of long clothes. 

Strict cleanliness is essential to the well-being of the infant ; and in 
nothing is the difference between a good and careless nurse more clearly 
evidenced than by the management of the napkins, and the protection of 
the parts from the contact of urinary and fecal discharges. Neglect here 
frequently gives rise to troublesome excoriation of the nates, or in the 
flexure of the groins ; and nothing, perhaps, is of more importance than 
that the child should be kept dry as well as clean. The use of the 
warm bath is universal ; but, as regards the frequency with which it is 
to be employed, some degree of discretion may be exercised in individual 
cases. Many nurses, after the first few days, undress and bathe the 
infant, if perfectly healthy, night and morning, and apparently with 
benefit as well as with safety. Caution should, however, in this respect, 
always be enjoined, as, in some instances, too frequent bathing seems to 
produce an exhausting eifect ; and, in the case of feeble or sick children, 
it may only be possible to insure cleanliness by rapid sponging, while the 
bath is either avoided altogether, or repeated only at intervals of two or 
three days. Daring the first six weeks the child should not be permitted 
to remain in the bath for more than two or three minutes. 

Light and air are as essential to the growth of a child as to that of a 
plant. At first, however, caution is, even in these respects, necessary. 
A dim and subdued light is thus more suitable, until the organs of vision 
become, in some degree, accustomed to the new stimulus ; and, in like 
manner, until the new function of respiration, and the maintenance of 
temperature, are efficiently and vigorously discharged, we must take care, 
in our anxiety for pure air, not to expose the infant to vicissitudes of 
temperature. In the warm weather of summer, it may be taken out 
somewhat earlier, although, as a rule, it is better not to carry the child 
out of doors before the end of the second week ; but, when this stage has 
been reached, nothing, perhaps, is of greater importance, or has a greater 
effect on the health and development of the infant, than its daily exposure 
in the open air, clothed according to the requirements of the season. 

During the weeks which immediately succeed its birth, the infant 
passes the greater portion of its time, by day as well as by night, in 
sleep ; but in this respect there is great variety, even with healthy chil- 
dren. For example, it often happens that they sleep quietly and almost 
continuously during the day, awakening only at intervals to go to the 
breast, while at night they are wakeful and restless. This, after a time, 
is often rectified by the management of an intelligent nurse, who, by 
keeping the child awake during a part of the day, or it may be, by 
bathing it at night instead of the morning, succeeds in breaking the 
habit, to the great relief and comfort of the mother, who otherwise has 
her rest broken and her nursing powers impaired. Sleep is certainly 
encouraged, and often very markedly so, by the daily exposure to the 
open air. 

The child should, for various reasons — some of which have been pre- 
viously mentioned — be put early to the breast. The laxative action of 
39 



610 THE NEWLY-BORN CHILD. 

the Colostrum generally produces the discharge from the bowels of the 
dark-colored meconium which is lodged there. It is too much the habit 
of nurses to dose the infant with castor oil, under the idea that it is neces- 
sary in order to set up the excretory function of the bowels. This prac- 
tice is no less deleterious in its results than it is irrational in theory ; and, 
in point of fact, there is no more fruitful cause of subsequent gastric irri- 
tation and intestinal derangement. The accoucheur should therefore put 
his absolute veto on any such treatment without his sanction, at least 
during the period while he remains in attendance. It is no doubt more 
frequently required when the child is being nourished with substitutes for 
breast-milk, but in the great majority of cases, it is, to say the least, 
perfectly unnecessary. Another very general practice, is, during the 
first two days, before the secretion of milk has been thoroughly estab- 
lished, to feed the child with sugar and water. The effect of this, too, is 
often the reverse of beneficial, as this syrup is not only unsuitable to the 
nourishment of a newly-born child, but it is also apt to derange the func- 
tions and to give rise to ulterior ailments which may be the cause both 
of trouble and anxiety. A mixture of cow's milk and water, with a very 
small proportion of sugar, — or, better still, of sugar of milk, — is a more 
eligible substitute ; but so soon as the milk becomes abundant, all such 
methods should be abandoned for the natural secretion of the mother's 
breast. 

Every mother should be encouraged to nurse her own offspring, unless 
under certain exceptional conditions, which have been referred to in the 
preceding chapter. For not only is this to her advantage ultimately, by 
preventing too frequent pregnancies, but it is to the advantage of the child, 
by furnishing it with what nature has specially provided for its support. 
What has already been said with reference to the function of lactation, 
is sufficient clearly to show how important is the management of that 
function, in its bearing upon the child, no less than upon the mother. 
Care should be taken from the beginning to put the child to the breast at 
something like fixed intervals, gradually extending the periods from two 
to four hours as has been already explained. Tliis, by allowing the breast 
to fill, and permitting the mother satisfactory and continuous sleep, goes 
some way to maintain the quality of the milk ; while, as regards the 
child, it gives the digestive and assimilative functions time to rest. There 
is certainly no more fertile cause of the minor digestive derangements, 
than the habits which prevail among the ignorant, of constantly putting 
the infant to the breast, as the ready method of cure for restlessness or 
screaming fits. 

Various circumstances, — sometimes occurring quite unexpectedly, — 
may render it impossible that the mother can nurse her infant. When 
this is the case, the medical attendant should always recommend that the 
services of a hired nurse be at once obtained ; and, if this recommenda- 
tion be acted upon, the duty of selecting a nurse devolves naturally upon 
him. This is a matter of no small importance. From what has been 
said in the preceding chapter as to the nutritive value of the milk in dif- 
ferent cases, it will be obvious that some caution m.ust be exercised, and 
especially that we should not too hurriedly infer, either from the abun- 
dance or the apparent richness of the milk, that the woman is to be looked 



SELECTION OF NURSES. 611 

upon with confidence, as necessarily a good nurse. There are certain 
other matters in regard to which it is our duty to inquire. We thus look 
narrowly, and as a matter of course, to the general health, circumstances, 
and age of the applicant ; a perfectly healthy young woman, from a 
country district, and hetween the ages of eighteen and twenty-eight, be- 
ing generally preferred. With reference to general health, some have 
attached considerable importance to the state of the teeth, as affording a 
reliable indication ; and, although this has certainly been exaggerated, 
there can be no doubt that the early loss of the teeth, and especially of the 
front teeth, by decay, is so far an unfavorable symptom. It is obviously 
our duty to determine, in so far as this may be possible, whether she is 
the subject of any disease which may be transmissible to the child. Any 
evidence, should it but amount to a suspicion, of serious organic disease, 
and especially of a phthisical tendency, may be held to warrant rejection. 
Unfortunately, the circumstances are such, in many cases, as to admit of, 
at least, the possibility of a syphilitic taint, and this is, therefore, a point 
in regard to which we should very specially be on our guard. To glance 
at the throat, the skin, the glands of the neck, and the hair, are, on this 
account, matters almost of routine in such investigations. We should 
also examine the breasts, not only with regard to their secretion, but as 
to the state of the nipple ; and the presence of severe excoriations, and 
still more of fissures at the base of the nipple, are to be held as un- 
favorable conditions : and this for various reasons, — one of the most im- 
portant of which is the fact, that we can have no confidence that she will 
prove a zealous and attentive nurse, if every application of the infant to 
the breast is attended with discomfort or suffering. If we have a choice 
in the matter, we should also select a nurse whose condition, as regards 
the age of the milk, is as nearly as possible that of the mother ; and if 
this cannot be attained, it is better that she should have been confined a 
little later than before her. It is always a matter of importance to be 
able to see the child of the nurse, as its condition may often be held 
to indicate the nutritive value of the milk. There are, of course, other 
matters, which have reference to the character and disposition of the 
woman, or to the fact of her having had previous experience in the rear- 
ing of children, which may be held as being of no small importance ; but 
these are, perhaps, questions which do not so immediately come under 
the cognizance of the medical attendant. 

The diet and regimen of hired nurses is a matter to which some promi- 
nence should be given. It is, indeed, of greater importance in this case 
than in that of the mother, that no overfeeding or other similar impru- 
dence should be permitted. The simple rule in all such cases should be 
that the woman is supplied with plain and easily digested food, which, in 
point of quantity, should be ample, but at the same time, not more than 
is requisite for the maintenance of perfect health. If, with the view of 
contributing to the health and vigor of the child, the nurse is plied, as is 
often the case, with strong soups, gruel, and stimulating articles of diet, 
at short intervals during the day, the result is likely to be exactly the 
reverse of what is anticipated, and the child suffers from over-richness of 
the milk, while the nurse becomes rapidly fattened. No rule can be laid 
down, however, as to the diet suitable for nurses ; beyond this — that a 



612 THE NEWLY-BORN CHILD. 

large proportion of their food should consist in the simple and possibly 
frugal fare to which they have been accustomed. In this way the 
danger to which we have referred may always be avoided, but everything 
will, of course, depend upon the habits of the country or district from 
which the nurse has been procured. In the rural districts of Scotland, 
for example, oatmeal, in the form of porridge, and generally eaten with 
buttermilk, is one of the most important items in the daily food of the 
masses, and is well known to be admirably adapted for women who are 
nursing, although it was some years ago stated in a report presented to 
Parliament on the dietary of the English prisons that the food referred 
to was " similar to what is used in England for the fattening of pigs." 
The habits of the English peasantry and of the lower classes in all large 
towns will require to be taken into consideration in the regulation of the 
diet. In Scotland, beer and other malt liquors are seldom used, and are, 
therefore, quite unnecessary ; indeed it may be said that if a woman 
cannot nurse without stimulants, her assistance may be dispensed with. 
But, in England, ^vhere the daily use of beer is all but universal, this, to 
which the woman has become accustomed, should always be given, as 
probably essential to the maintenance of her physical condition. 

The infant, if healthy, instinctively seizes the nipple from the first and 
sucks vigorously, and indeed has often been seen to suck the finger of 
the accoucheur before the trunk was born. It is not, however, always 
so. The difficulty arises, in many cases, from a peculiarity in the con- 
formation of the nipple, which may either be unusually small, or — ^what 
is more common — has been carelessly allowed to be pressed in by the 
dress during pregnancy. This may generally be got over by having the 
nipple drawn out by the nurse or by a strong child, by the breast-pump, 
or by a soda-water bottle used like a cupping-glass, care being taken not 
to permit the parts to relapse into their former condition. With care 
and proper management on the part of the nurse, this difficulty is seldom 
a serious one. The child may, in other cases, especially when born pre- 
maturely, be unable by Aveakness to take the breast, a condition which 
is highly unsatisfactory. The woman, in these cases, should milk her 
breast into the mouth of the child, when it will generally swallow the 
milk as it flows ; or she may drain it off by the pump, and feed the infant 
by a spoon ; but the objection to this is that it is a bad plan to use a 
spoon if it can be avoided, for the child thus becomes accustomed to the 
spoon, and still further loses the instinct for the nipple. An idea exten- 
sively prevails among the lower classes that w^hen a child has difficulty 
in sucking, or refuses the breast, it is "tongue-tied," but this is an ob- 
vious error. It, no doubt, does happen, although very rarely, that the 
frgenum of the tongue is too short, or attached too far forward, but in 
ordinary practice it will probably not occur oftener than once in a life- 
time that the accoucheur is obliged to divide the fraenum for this variety 
of congenital malformation. 

It is the duty of the accoucheur to examine the child after its birth, 
and to inquire on his subsequent visits as to its various functions, in 
order that congenital malformations may not be overlooked. It may 
thus become evident, either immediately or shortly after birth, that the 
child is affected with some peculiarity which must be remedied in order 



DIARRH(EA. 613 

to save its life. Such malformations as harelip fall more properly into 
the domain of surgery, but in the case of an imperforate condition of the 
anus or urethra, the general practitioner must be prepared to act 
promptly. In the former, an operation is necessary by incision in the 
direction of the rectum, or it may even be necessary in extreme cases to 
form an artificial anus. Imperforate urethra, again, is rare, probably 
for the reason which is pointed out by Burns, that "generally the canal 
opens, in supposed cases of imperforation, about midway between the 
scrotum and glans penis ;" and the result of experience seems to be that 
perforation of the glans seldom succeeds, so that it would probably be 
better to cut down upon the urethra than attempt to find its extremity. 
It may be necessary, even where there is no closure, to pass a probe or a 
very small elastic catheter into the bladder, in consequence of retention. 

We are often told, a considerable time after delivery, that the child 
has not made water. On such information, however, we must never 
act, unless there is some evidence of distension of the bladder. The 
urine is often voided in the bath, and thus escapes the notice of the 
nurse ; and, if retained for a longer period than usual, the application of 
cold water over the hypogaster, or a teaspoonful of cold water given by 
the mouth, will generally have the effect of causing contraction of the 
viscus. Nor is tardy action of the bowels to be held as necessarily 
indicating the administration of laxatives ; for, in this as in the other 
case, nature generally will, if left to herself, bring the function into 
perfect order without any extraneous assistance. We must, in like 
manner, be cautious in the administration of such drugs as are usually 
employed in the treatment of diarrhoea. Be it remembered, in the first 
place, that there is, in healthy children, the greatest possible difference 
in the manner in which the bowels discharo;e their functions. In one the 
frequency and the character of the evacuations may seem to amount to 
diarrhoea, and in another the dejections are habitually costive ; but, so 
long as the infant remains in perfect health, drugs of all kinds are to be 
scrupulously withheld. In many cases, we may succeed in producing 
the effect which we desire by administering a given drug to the mother 
and thus influencing the composition of the milk, but we can scarcely be 
too cautious in any attempt to act directly upon the child. 

Diarrhoea^ although of more frequent occurrence during the process 
of dentition, may happen at any period subsequent to the birth of the 
child. A strict attention to the directions which have been given above 
will suffice, as we have reason to believe, in most cases, to avert many 
special conditions which are apt to lead to this troublesome affection ; but, 
even under circumstances the most favorable, the diarrhoea of infants is 
only too familiar from its frequent occurrence. The ordinary " simple" 
or " catarrhal" variety of diarrhoea, which is the most frequent, is also 
the least serious ; but, in the case of the newly-born child, the enormous 
quantity which is sometimes poured out may reduce the strength of a 
puny infant so rapidly, as to place it in a most critical condition in the 
course of a few hours, without any evidence whatever of inflammatory 
action. If the action of the bowels is accompanied with obstinate vomit- 
ing, the case may be looked upon as much more alarming in its nature ; 
but simple, uncomplicated diarrhoea is seldom dangerous, unless it passes 



614 THE NEWLY-BORN CHILD. 

into the more serious variety. The appearance of the discharge, as seen 
on the napkins, varies greatly, from a watery and almost colorless fluid 
to a slimy matter, which may be frothy or bright yellow like the yolk of 
an egg, and in other cases green, mixed with fragments of curdled milk, 
and possibly streaked with blood. A much more alarming variety is 
where the diarrhoea takes the " inflammatory" or " dysenteric" form, 
when it is generally attended with corresponding gastric disturbance, 
and with a marked increase in the temperature and in the frequency of 
the pulse. Between the extremes, the varieties in individual cases are 
endless, and, consequently, the treatment which may be held as applicable 
in each must vary in a corresponding degree. 

Unless on an emergency arising from the violence of the symptoms, 
we should always, in very young children, try the milder measures first. 
A teaspoonful of lime-water given with a little boiled cow's milk, or 
with the milk of the mother, has often a marked and immediate eff'ect. 
The number of cases which may be traced to imprudence in the dietary 
of the mother or the nurse is, we believe, much greater than is generally 
supposed ; and we would, therefore, recommend that this should always 
be inquired into, and, if necessary, modified without delay. Should the 
presence of blood in the stools, an appearance of tenesmus, and general 
inflammatory symptoms, indicate the existence of the more serious 
form, nothing has a better effect, if it can be retained, than castor oil 
with a single drop of laudanum. Among other available astringents 
are the tinctures of catechu or kino, which may be administered in the 
usual way with chalk mixture, to which may be added, in the event of 
flatulence being a concomitant symptom, a proper proportion of pepper- 
mint or pennyroyal water. The young practitioner cannot be too cau- 
tious in the use of opium in any of its forms ; for, although he may thus 
succeed in checking the discharge, the benefit which results is often tem- 
porary in its character, and, indeed, the symptoms would sometimes seem 
to come on after opium worse than before. The bright green appearance 
of the evacuations, to which reference has already been made, is not to 
be looked upon as necessarily a very unfavorable condition ; and one 
object in mentioning the fact at this place is that this condition seems 
somewhat too frequently to be admitted as a reason for the administra- 
tion of powerful drugs. When, at a somewhat more advanced age, the 
child is being fed, an alteration in its diet and a recurrence to the sim- 
pler nourishment of the early months will often suffice to arrest the 
symptoms. 

In the case of habitual Constipation^ a favorite remedy is manna 
given with milk. Nothing is easier, of course, than to move the bowels, 
either by this, by castor oil, or by any other laxative ; but it will gene- 
rally be found that if we begin with laxatives, they must be continued. 
On this account, many nurses prefer to use an injection of soap — or to 
pass into the rectum a small piece of soap, which is cut so as to admit 
of its easy introduction. We cannot doubt, however, that a large pro- 
portion of such cases are unnecessarily treated, and would do quite well 
if left alone. 

It is only possible for us very briefly to notice a few of the more 
common ailments which afi'ect the infant shortly after its birth. The 



ICTERUS NEONATORUM. 615 

vulgar nomenclature of these disorders has unfortunately shrouded the 
subject with an obscurity, which the limited knowledge of most midwives 
rather tends to deepen. Such terms as " hives" and " gum" are familiar 
in the mouths of experienced matrons of the lower class ; but, unfortu- 
nately, indicate nothing — or, rather, so many different things, that the 
words have lost any scientific signification which they may have had. 
One of the most common of the affections alluded to is what is known as 
Icterus Neonatorum. It was at one time generally supposed that this 
very common affection indicated some serious pathological condition, the 
liver as well as its function being believed to be implicated. The chief 
symptom of this familiar affection is a tinging, more or less marked, of 
the skin, which becomes of a yellow color. In immature or feeble 
children, this gradually deepens, and distinctly affects the conjunctiva ; 
while the colorless condition of the evacuations points still more clearly 
to the analogy which subsists between this and ordinary jaundice. Al- 
though it may be too much to suppose, as some have done, that this is a 
'' perfectly natural state, in which the skin and other secreting organs 
are called on for a few days to assist in disposing of the bile, until the 
demand for it to minister in the digestive function becomes equal to its 
abundant supply," we may, in the case of a child otherwise healthy, 
look upon the phenomenon in question without the slightest apprehension. 
If excessive, it is usual to give a grain of Hydrarg. c. Greta, followed by 
a small dose of castor oil: but even this is rarely necessary, as the dis- 
coloration generally passes off spontaneously, and almost as rapidly as it 
came on. 

We may here briefly advert to one other of the affections of infancy, 
which is generally, although not invariably, associated with impaired 
nutrition. This is familiarly known under the name of Thrush. If we 
look into the mouths of children who are the subjects of this affection, 
we observe on the surface of the mucous membrane of the tongue, lips, 
and cheeks, a number of small, circular, white spots, which appear at 
the first glance as if minute portions of curdled milk had adhered to the 
surfaces in question. A more careful examination shows either that 
they cannot be detached, or, if so, that the subjacent surface presents 
an eroded appearance. Microscopic researches, as to the nature of this 
affection, have proved that it is due to the presence of a cryptogamic 
vegetation, which is, more or less obviously, associated with derangement 
of the digestive functions. It has been conclusively demonstrated that 
this may be transplanted from one mucous surface to another ; and we 
have seen more than one case in which a troublesome affection of the 
nipples, and of the contiguous cutaneous surface, had apparently been 
directly produced by it. The treatment will consist in such measures as 
may remedy the digestive ailment upon which it is presumed to depend ; 
and, at the same time, the local affection is to be treated by the applica- 
tion of a solution of twenty grains of borax in an ounce of water, Avhich 
may be replaced in the more obdurate cases by a solution of chlorate of 
potash, or even by a solution of nitrate of silver, of four grains to the 
ounce of distilled water. 

In cases in which the parents are not in circumstances to afford the 
services of a wet nurse, and in other instances in which there is an un- 



616 THE NEWLY-BORN CHILD. 

conquerable repugnance to the employment of a hired nurse, it may be 
necessary, from the first, to rear the child by the use of certain substi- 
tutes for breast milk — its natural food. Our primary object must, there- 
fore, be to provide such nourishment for the infant as may, chemically 
and otherwise, most nearly resemble that which nature provides. Asses' 
or goats' milk probably approach in their composition nearest to the 
secretion of the mammary gland in the human female, and, if obtainable, 
may on that account be preferred. The objection to the milk of the cow 
is, that it is so much richer in the corpuscular element that, if given 
undiluted to a young infant, it rarely fails to engender some form of 
gastro-intestinal disorder. This is, however, in the vast majority of 
cases, the best substitute which is within reach ; and, as the fundamental 
objection to its employment is its richness, experience has shown that 
simple dilution with water furnishes a material by which hundreds of 
thousands of infants are, without difficulty, reared in this country. Still, 
even under circumstances the most favorable, it is obvious that the best 
substitutes for breast milk are open to objection ; and we are, therefore, 
not astonished to find that infants, thus artificially reared, are more liable 
to disease, and more likely to succumb to it. On this account alone, 
were there no other argument in favor of it, it is the duty of the accou- 
cheur to insist, as far as he can, upon all children being reared at the 
breast; and, in the case of children born prematurely, he should abso- 
lutely refuse his sanction to any proposal otherwise to nourish them. 

The amount of water to be added to cows' milk will, of course, depend 
upon its quality. If rich and pure, an equal bulk, or even more, of 
water may be added, but it is, in towns at least, rarely necessary to add 
more than a third of water, in order to reduce an average specimen to 
the extent which is requisite. Such a mixture as this is, as compared 
with human milk, deficient in the saccharine element, and it is on that 
account usual to sweeten it with the ordinary sugar of commerce ; but 
what should always be preferred, w^hen it is within reach, is the sugar of 
milk, w^hich is now prepared in considerable quantities for this purpose 
from the whey of cow's milk. The mixture should always be given 
warm, about blood heat, to which temperature, therefore, it must be 
artificially raised. A great variety of nursing bottles have been devised, 
most of them being simple as well as ingenious in construction, with the 
object of enabling the child to suck from an artificial nipple at the ex- 
tremity of the apparatus. In a word, our whole object is — when a child 
has to be reared artificially — to assimilate all the conditions as nearly as 
possible to those which exist when the natural source is available. The 
success of bottle feeding depends very greatly upon the care and expe- 
rience of the mother or nurse, and upon nothing does the ultimate result 
hinge more than upon strict attention to cleanliness. It is well known 
that it is more difficult thus to rear a child in summer than in winter, 
from the rapidity with which, in the former case, the temperature acts 
upon the milk. It is also well known that, when the apparatus is not 
kept scrupulously clean, small particles of curd are apt to accumulate 
within it or the tube, and these again, if swallowed by the infant, are 
more than likely to excite gastric or intestinal disturbance: but these 
difficulties are fortunately in a large majority of cases completely over- 



ARTIFICIAL NURSING. 617 

come, and the infants, if originally vigorous and mature, are often pic- 
tures of health. 

So long as, under such alimentation, the functions of digestion and 
assimilation are perfectly discharged, we may well be content with the 
condition of the child ; but when, as occurs in a certain proportion of 
cases — the child pines and is not thriving^ the digestion is impaired, or 
obstinate diarrhoea supervenes, we must, without delay, adopt means for 
its relief. It is usual, when at all practicable, to obtain the milk for an 
infant from one cow, and what, in the condition alluded to, has often been 
found sufficient is simply to change the cow, as, under other circum- 
stances, we might do with the nurse. But, when this and other simple 
remedial measures fail in producing an effect, and the infant continues to 
droop, we should lose no time in urging that a nurse be obtained at once. 
In many cases this is delayed until the condition of the child becomes 
critical, and the assistance of the nurse, when eventually obtained, is too 
late to rally the little sufferer from the condition into which it has fallen ; 
and, in fact, this question often devolves a serious responsibility upon the 
medical attendant, who is certainly blameworthy if he fail to interpose 
his authority before it is too late. 

The period at which other articles of food are to be permitted to the 
child, is another question in regard to which we are often expected to ex- 
press an opinion. Much will no doubt depend upon the health of the 
mother, and the abundance or otherwise of the lacteal secretion, but we 
have great reason to believe that the tendency is considerably to antici- 
pate the period at which a variety of diet may stifely be permitted. We 
think we are justified in concluding that, for the first three months, milk 
and milk alone is the best as well as the most natural food for the child ; 
but, in this as in most other respects, the safest and most reliable indica- 
tion is to be found in the condition of the child itself. So long, indeed, 
as its appearance and development, the manner in which its functions are 
discharged, and the extent to which it enjoys refreshing and quiet sleep, 
indicate perfect health, too much caution cannot be exercised in sanction- 
ing any change, unless indeed the interests of the mother should render 
it imperative. 

Of the many substances which have been employed as substitutes for, 
or supplementary to, milk in the alimentation of infants, nothing has, 
perhaps, of late years attracted more attention than the Food for Infants 
which was devised as the result of much original research by Baron 
Liebig.^ Boiled bread and milk, arrow-root, corn flour, and a host of 

' This may be obtained in any quantity, carefully prepared by eminent chemists, 
but as its price puts it beyond the reach of the humbler classes, we are induced to 
borrow some sentences from a little pamphlet published on this subject by a lady, 
whose main object was to bring the food within the reach of all. " The ingredients 
required," she writes, " are the following : — 



Malt 


h oz. 


Second Flonr 


. . } oz. 


Skimmed Milk . 


(J oz. 


Water .... 


1 oz. 


Bicarbonate of Potash 


7i grains, 



" I may mention here that, after picking out other seeds which are often found 
among malt, and which may be injurious, the malt should be crushed in a mortar or 



618 THE NEWLY-BORN CHILD. 

simple an^l easily digested substances are extensively employed, the 
articles selected depending more upon the fancy or prejudice of the nurse 
than on any marked saperiority of one over another. Nothing, we are 
assured, is better than rusks, if they can be obtained of good quality ; 
and if well made they require no boiling > but are to be covered for a 
minute or two with boiling water, which is then poured off, and milk or 
cream, with a very little sugar, added before it is broken up. When the 
child grows older, a little carefully made chicken-soup or beef-tea may 
be given twice a week ; and, by thus adopting each change of diet with 
caution, it may be gradually altered so as to suit the increasing require- 
ments of a higher stage of development. 

Wemiing. — The separation of the child from the mother involves some- 
thing of a crisis in its existence, and is generally, as might be expected, 
attended with more or less constitutional disturbance. The condition of 
the mother must necessarily, as has already been shown, point clearly in 
many cases to the conclusion that the infant should, in her interest, be at 
once withdrawn. But, when circumstances are in all respects favorable, 
it has in every instance to be determined what is the proper period for 
weaning — what time, in the interests of both, is to be selected for the 
severance of that physiological tie which binds together the mother and 
her offspring. It is very unusual to wait until the occurrence of preg- 
nancy, or the condition otherwise of the mother, show clearly that she is 
no longer able to supply proper nutriment to the child. Were we even 
to look at the case without any reference whatever to the maintenance of 
her health, a verj^ little reflection should suffice to show that nursing be- 
yond a certain average period is little likely to maintain the health or 
well-being of the infant; but as, in this matter, the interests of the mother 
are in a sense inseparable from those of the child, it is sometimes a ques- 
tion involving both care and discrimination absolutely to fix the time for 
weaning. 

It has frequently been asserted that the natural period for separating 
the child from the mother is on the completion of the process of denti- 
tion ; and it may, perhaps, be admitted that, theoretically, the idea is 
not destitute of validity. Every one knows, however, that, although it 
may be possible to nurse for two years — the period at which the first 
dentition is usually completed — the amount of milk secreted ceases long 
before that to be sufficient for the nourishment of the child. Indeed, the 
cases are exceptional in which a woman is able to suckle her child, with- 

ground in a cofFee-mill. Mix all the ingredients together, and put them in a pan 
thoroughly clean, boil for six or eight minutes, stirring all the time ; remove from the 
fire, strain through an ordinary sieve or piece of muslin, and give to the child through 
a feeding-bottle. See that the holes in the nipple of the tube are large enoiigh to 
admit of the food passing through them, and that it be not given too warm. The 
above quantity daily will be found sufficient for an infant for the first few days ; but 
very soon it will have to be increased to two or three cupfuls, and more. For a new- 
born child who has to be fed entirely on this food, it should be made at first half milk 
and half water. Use skimmed milk ; new milk is too strong. If properly made, the 
food should be quite sweet, and taste as though sugar had been put into it ; but 
sugar must on no account be used. The quantity required for twenty-four hours may 
be made at once, and heated for use as required. Malt can be had at the bakers', who 
use it for making bread. It is dry and slightly crushed, and should be ground fine 
before using ; this can be done in an ordinary coftee-mill." 



WEANING. 619 

out assistance in the way of extra aliment, for a longer period than ten 
months ; and a large proportion of mothers and nurses require supple- 
mentary aid much sooner than this. In cases, therefore, of protracted 
lactation, the breast milk is generally an insignificant portion of the total 
nourishment ^vhich is given to the child ; and we can scarcely doubt that, 
under such circumstances, weaning might have long before been effected, 
in the interest of the infant, as well as in that of the mother. For while, 
on the one hand, a deteriorated lacteal secretion can scarcely fail to 
exercise a pernicious influence on the child ; so, on the other hand, a 
long-continued drain on the system is seldom without its effect on the 
health of the nurse. 

With a healthy and vigorous nurse, it is better that the child should 
have nothing but what she can afford it for the first six or seven months; 
and, certainly, the practice of feeding the infant during the night, so as 
to avoid trouble and disturbance to the mother, which has become too 
common of late, is one to which — save under exceptional circumstances — 
we should give no countenance. A partial failure in the quantity or 
quality of the milk, may, no doubt, occur at a period very much earlier 
than that to which we refer ; so that it may be absolutely necessary, even 
at the second or third month, partially to feed, while nursing is simulta- 
neously going on. It is, in all cases, advisable to accustom the infant to 
other food before the breast milk is withdrawn; otherwise, the process 
of weaning is much more troublesome, and is more likely to be produc- 
tive of unsatisfactory results. When this is done, and when the proper 
times arrives, the quantity of milk should be gradually and steadily di- 
minished, and the proportion of other nutriment correspondingly in- 
creased, until the latter alone remains. Seldom, however, is this effectual 
without more or less of trouble, arising from the restlessness which the 
deprivation of the milk excites in the child ; bat, if the weaning process 
has not been too abrupt, the screaming fits and other evidence of discom- 
fort will not last beyond a couple of days. And, as regards the mother, 
any discomfort which she may experience may be easily kept within 
moderate bounds by saline laxatives, abstinence from fluids, and the ap- 
plication of belladonna or cooling lotions to the breast, until the gland 
ceases to discharge its function. 

The general health of the child is the point which, above all others, is 
of importance in its bearing on the period to be selected for weaning. 
It is proper, therefore, to await the subsidence of any febrile attack or 
even an ordinary catarrh, or any other trifling ailment before weaning the 
child ; and it is, we may say, the universal practice to regulate the pro- 
cess, in some measure, by the progress of dentition, which is, as we shall 
see presently, almost invariably marked by stages, these being separated 
by intervals during which such constitutional disturbance as may attend 
the eruption of the teeth completely disappears. It is well, therefore, to 
select the latter periods as those at which constitutional irritation is less 
likely to be engendered. There is, as we may well suppose, the greatest 
difference in the ease with which children are weaned — the deprivation 
causing, in one case, scarcely a gesture indicating uneasiness or discom- 
fort, and, in another, a degree of fretfulness, and even of constitutional 
disturbance, which seems quite out of proportion to the cause. This de- 



620 THE NEWLY-BORN CHILD. 

pends, no doubt, upon the temperament, or possibly, upon constitutional 
causes ; but there is every reason to believe that the idea, which has so 
long obtained, in regard to the bearing which the progress of dentition 
should have on the question of weaning, is well founded, and ought, in 
all cases, to be admitted, as affording indications of no small importance. 
But to attempt to fix absolutely the period of weaning, as applicable to 
all cases, is as absurd in theory as it would be found to be unsatisfactory 
in practice, were it for no other reason than the well known irregularity 
which attends dentition. In the case of a perfectly healthy infant, and 
an average result in the eruption of the teeth, we may, however, assume 
that ten months is a proper period for weaning, as at this time there is 
usually a pause in the process of dentition, subsequent to the appearance 
of the eight incisors. 

Defitition. — Among the many reasons which indicate the necessity for 
a careful alimentation of the child during the early months of its exist- 
ence, there is perhaps none of greater importance than that the system 
may be prepared for the contingencies which so often attend the erup- 
tion of the teeth. From imperceptible constitutional disturbance, to 
convulsions and derangement of all the functions at the cutting of every 
tooth, — which may be held as indicating the extremes, — cases offer 
themselves presenting every conceivable variety, of symptom intermediate 
between the two. There are few more perfect illustrations of the deli- 
cate sympathy which exists between functional disturbance and distal 
irritation, than are afforded by watching the progress of the first denti- 
tion. As a rule, indeed, the symptoms are merely those of local irrita- 
tion ; but in a large proportion of all cases, the sympathy referred to is 
evidenced by more or less of gastro-intestinal derangement, while, in a 
considerable number of instances, a reflex irritation is manifested in 
symptoms which indicate, more or less clearly, a disturbance of the 
nervous centres. 

Although, as a general rule, the development of the milk teeth within 
the jaw involves neither local nor constitutional disturbance, and it is 
only as they are about to penetrate the gum that the symptoms to 
which we have alluded first manifest themselves, the influence of the 
process is sometimes exhibited a considerable time before the teeth 
upon which the phenomena depend make their appearance. So long 
as no tumefaction, or other morbid condition of the gum, is observable, 
our treatment can only be expectant, or, at least, directed to the func- 
tions which are disturbed ; but this is clearly one of the conditions to 
which we have already referred as indicating the necessity of caution 
in the matter of weaning — for there can be little doubt that, in such 
cases, a change, and especially a sudden change, in the nature of the 
food is very likely to be followed by an aggravation in the general 
symptoms. Such a state of matters is, in fact, sufficient warrant for 
protracting the period of nursing until more favorable conditions mani- 
fest themselves, which will generally be the case on the eruption of the 
first teeth. 

Although the process is subject to many irregularities, the teeth gene- 
rally make their appearance in a certain order, as is represented in the 
following formula, where the figures indicate the month at which, in ma- 



TEETHING, 



621 



ture and healthy children, we may expect the various teeth, the dentition 
usually commencing with the incisors of the lower jaw : — 



Molars. 


Canine. 


Incisors. 


Canine. 


Molars. 


24—12 


18 


9—7—7—9 


18 


12—24 



From this it appears that the milk teeth — which are twenty in number — 
come through the gums in the following order. It is, of course, under- 
stood that an infant may be born with teeth, or may not have a tooth 
until several months later than is indicated by the formula, and in either 
case without a single special symptom. On an average, then, the cen- 
tral incisors make their appearance in the course of the seventh month, 
and are followed, about the ninth, by the lateral incisors. After this, 
which is the time generally selected for weaning the child, there is a 
pause of something like three months. At the end of these three months, 
the first molars come to the surface ; and, at intervals of six months, the 
canines and second molars respectively, — so that the dentition is usually 
completed about the end of the second year. If the delicacy of the 
child on the one hand, or premature or irregular eruption of the groups 
of the teeth on the other, should disturb our calculations, it may be 
necessary to modify the ordinary routine procedure : and, in any case, 
the symptoms of irritation, local or general, to which reference has been 
made, and which indicate the approaching eruption of a tooth or group 
of teeth, should be held as warranting us in postponing the period for 
weaning. 

A very limited experience in the treatment of the diseases of infancy 
is sufficient to show that the eruption of the deciduous teeth is intimately 
connected with many of the most important of these. It has, on this 
account, been admitted from time immemorial that the management of 
children during teething, is a point which often involves both responsi- 
bility and anxiety. It is, however, a matter which can admit of no 
doubt that a knowledge of this familiar fact leads in no small number of 
cases to illogical inferences and slovenly practice. Nothing can well be 
imagined more irrational than to suppose that all the ailments which may 
affect the child during the period of dentition, depend upon local irrita- 
tion, due to the impending eruption of the teeth ; and it is scarcely less 
absurd to conclude that all irritation is to be relieved by the promiscuous 
use of the gum lancet. On the latter point. West well observes that — 
" such a proceeding is nothing better than a piece of barbarous empiri- 
cism, which causes the infant much pain, and is useless or mischievous in 
a dozen instances, for one in which it affords relief."^ 

So long as the process of teething is going on quite naturally, or is 
only accompanied with restlessness or slight fever, the less we interfere 
the better. The progress of the tooth towards the surface is necessarily 



slow, but the manner in which the tissues of 



the 



which cover it are 



1 See on this subject a very able and exbaustive series of papers " On the Dangers 
of Dentition," by Dr. James Finlayson, in the Obstetrical Journal for 1873-74. 



^ 



622 THE NEWLY-BORN CHILD. 

gradually attenuated, so as to admit of its final emergence, form no ex- 
ception to the generally admirable manner in which nature discharges 
her manifold functions in the animal economy. And yet it is too much 
the fashion in many quarters to have recourse to the lancet, in a very 
large proportion of cases, its use being supposed to be indicated by any, 
even the most trivial, of the ailments of infancy. In certain cases it is 
admitted that the lancet is the proper and only treatment ; but, the more 
carefully we watch the natural process, the more cautious do we become 
in resolving upon lancing the gums of an infant. The conditions which 
may be admitted as warranting the operation are mainly these : 1st. 
When the child is suffering, and the tooth is so nearly through that we 
are sure that cutting down upon it will at once relieve the tension, and 
permit of the passage of the tooth ; 2d. When the gums are swollen, hot, 
and tender, and obviously more vascular than usual, but in this case we 
operate, not with the view of bringing the tooth through, but to give 
relief to local symptoms, upon which constitutional disturbance may be 
supposed to depend ; 3d. The occurrence of convulsions during one of 
the periods of active dentition is generally, and with perfect propriety, 
looked upon as justifying us in using the lancet, even although the state 
of the gum may not seem to warrant the operation. This we do, less 
from a conviction that the procedure is likely to be efficacious, than in 
the hope that it may prove so. When a tumid state of the gum is asso- 
ciated with aphthae, or with that severe variety of inflammation of the 
gum to which in infants the name of Odontitis has been given, the use of 
the lancet, far from being beneficial, only makes matters worse. And 
where, in the case of tense and swollen gums, it is employed, not for the 
purposes of scarification, but in the expectation of bringing the tooth 
through, there is some reason to fear — and, indeed, this is a point which 
is very generally believed — that an incision of this kind may result in a 
cicatrix, ultimately rendering the passage of the tooth through the gum 
more difficult than if we had left it untouched. 

The mode of cutting the gum varies according to the nature of the 
tooth over which we are operating. In the case of the incisors, the in- 
cision should be longitudinal, and directly along the cutting edge of the 
tooth. As regards the molars, again, it is usual to make a crucial 
incision. While we are inclined to think that the idea of a cicatrix in 
the gum proving a serious obstacle has been in some degree exaggerated, 
we think that it is well to avoid, if this be practicable, the possibility of 
any such result. This may be done in a very simple way by so operating, 
when we cut or scarify the gums with the mere object of depletion, as to 
avoid that portion of the surface through which the tooth must ultimately 
pass. We have generally found that scarification practised, not over the 
alveolar ridge, but near the base of that portion of the gum which is 
chiefly affected, has a perfectly satisfactory effect, and besides this will 
also be found in most cases to be attended with a more considerable flow 
of blood than when we proceed in the usual way. It often happens that 
the effect of scarification of the gums, although marked, is but temporary, 
and, on that account, it is frequently necessary to repeat the operation 
again and again, to subdue symptoms which are exceedingly apt to 
recur. 



DISEASES OF THE PUERPERAL STATE. 623 

In the treatment of Odontitis, the lancet shoukl be scrupulously 
avoided, as there is here a tendency to the formation of troublesome 
ulceration at the site of any incision or scarification ^vhich may be prac- 
tised. Our attention should, in such cases, be directed to the state of 
the digestive functions ; and, by a careful regulation of the diet and 
otherwise — while the local affection is to be met by the application to 
the affected surface of a solution of borax, with or without the chlorate 
of potash — the symptoms will generally in some degree be controlled. 
The latter drug may also be given internally, in the manner suggested 
by Dr. Hunt, in doses of two grains every four hours. 



CHAPTEE XL. 

PHLEGMASIA DOLEXS. 

The Puerperal State in its Relation to Disease. — Phlegmasia Dolexs: Xomen- 
clature. — Causes ; after Labor, and when Unconnected with Delivery. — Si/mj)- 
toms: Premonitory Signs : Pain: White Swelling : Tension: Heat: Consti- 
tutional Symptoms : The Limb Pits on Pressure during Conralescence : Loss 
of Power in the Limb. — Morbid Anatomy : Character of the Effused Fluid: 
Plugging of the Veins: State of the Lymphatics. — Pathology : Milk-Leg : 
Angeioleucitis : Crural Phlebitis: Exjjeriments of McKenzie and H. Lee: 
Views of Tilbury Fox : Review of the Pathology of the Subject. — Treatment: 
Ls Blood-letting justifiable? Blisters: Bandaging: Is Contagion Possible? 
General Treatment to be directed as a rule to a Condition of Debility: Tonic 
Regimen : Antiseptic Remedies — Causes of Protracted Convalescence. 

Passing now^ to the consideration of what are essentially Diseases of 
the Puerperal State, we observe that, apart from such affections as are 
assumed to belong to the condition referred to, there is ample evidence 
of a peculiar constitutional sensitiveness, one effect of which is to increase 
the gravity of symptoms arising from what, under other circumstances 
we would call quite ordinary diseases. There is, in fact, no disease to 
which a recently delivered woman is not as liable as others ; but in her 
case there is this special danger, that what we would call but a trivial 
ailment may, in consequence of the special conditions under which she is 
placed, be attended with symptoms of serious and alarming import. An 
ordinary catarrh, for example, may so disturb that repose of the func- 
tions, Avhich seems to be a prominent characteristic of the puerperal state, 
that an amount of constitutional disturbance is produced out of all pro- 
portion to the essential nature of the disorder. A state which is natu- 
rally one of calm quiescence is changed to a condition in which a turbulent 
circulation, arrested secretions, and violent fever, give no small cause for 
anxiety ; and it is on this account that we so carefully guard against the 



,^ 



624 PHLEaMASIA DOLENS. 

occurrence of such influences as may change the case at once from a 
favorable into an unfavorable category. All ordinary diseases, then, 
which are accompanied with what are called febrile symptoms, are looked 
upon with considerable apprehension, as they are apt to be accompanied, 
in the special cases in question, with a train of supernumerary symptoms 
which are held as characteristic of the puerperal state. 

It is, perhaps, in a sense, not too much to assume, that what are called 
the diseases of the puerperal state are merely more marked illustrations 
of the condition to which we refer. The peritonitis, the metritis, the 
mania of a puerperal patient, are thus nothing more than familiar diseases 
modified by special conditions, one of which is what w^e have ventured to 
call, for lack of a better name, a peculiar constitutional sensitiveness. 
We are amply warranted, however, as the sequel will show, in consider- 
ing each of these affections with reference to the period succeeding de- 
livery ; and we shall find that, not only are the symptoms modified, but 
they are so to such an extent as to require, in many cases, a treatment 
quite different from that which is supposed to be applicable to the disease 
in its ordinary form. 

Phlegmasia Dolens, or Phlegmasia Alba Dolens — the disorder which 
forms the subject of this chapter — forms no exception to the rule just 
stated. It is, indeed, more strictly a disease of the puerperal state than 
many of the affections which we shall have to consider, inasmuch as it is 
seldom observed save as associated with recent delivery. That the puer- 
peral state is not, however, essential to its manifestation is universally 
admitted, as it is sometimes met with in women who have never been preg- 
nant, and even in persons of the opposite sex. Few diseases have had 
a greater variety of designations applied to it than this ; anasarca serosa, 
'pJilegmasia lactea, oedema lactewn, white leg, and crural phlebitis, being 
but a few of the many appellations under which it has been described, a 
study of which, indeed, is not uninstructive, as it almost gives an epitome 
of the various pathological theories which have been successively ad- 
vanced to account for the somewhat peculiar phenomena of the disease. 
Excluding the very few cases in which it, or a precisely similar condition, 
has been observed to attack the arm, phlegmasia dolens consists in a white 
painful swelling of the leg. Although, as we have said, it is not neces- 
sarily associated with the puerperal state, it is almost always observed 
in women who have been recently confined, the period of its occurrence 
varying from the fifth to the thirtieth day, and, in very exceptional cases, 
at an earlier or later date than the extremes mentioned. It is more com- 
mon in pluriparse than in primiparse, and is more likely to occur in women 
who are of a feeble and delicate constitution than in those who are robust. 
In a very considerable number of cases, it has followed the various acci- 
dents and complications of delivery, and has been noticed to occur more 
frequently after removal of a retained placenta. All English writers on 
the subject agree in asserting that it usually attacks the left in prefer- 
ence to the right leg, Avhich Mr. White, of Manchester, seemed to think 
was due to the fact of women in this country habitually lying oji the left 
side during labor ; while Dr. Ramsbotham supposed that it " may possi- 
bly, in some inexplicable manner, be dependent on the different distribu- 



SYMPTOMS. 625 

tion of the right and left spermatic vein — the right terminating direct in 
the vena cava, the left in the renal." 

In no class of cases has it been so frequently observed as in women 
whose strength has been reduced to a low ebb by hemorrhage either dur- 
ing or after labor ; and this, no doubt, accounts for the observation made 
by Merriman that it is relatively of common occurrence after placenta 
prgevia. Women who have once suffered from phlegmasia dolens are by 
no means so liable to it in subsequent pregnancies as we might perhaps 
be disposed to anticipate ; and it has generally been observed that when 
it does so recur the subsequent attacks are much less violent. Mr. White 
says that he never knew it happen to a woman more than once ; but this 
does not tally w^ith the experience of most modern practitioners. One 
very troublesome and annoying peculiarity of this affection, is the ten- 
dency which the disease has, after having partially run its course in one 
leg, to be transferred to the other, and there pass through the same tedi- 
ous stages, still further reducing the strength of the woman, and post- 
poning the period of her convalescence — it may be by several months. 

It may be interesting here to mention the circumstances under which 
phlegmasia dolens has been observed when unconnected with recent de- 
livery. Puzos and, since his time, many modern writers have recorded 
cases in which all the usual phenomena have been manifested in the course 
of pregnancy. In a more considerable number of instances, it has been 
observed as occurring after abortion, particularly in cases in which the 
placenta or any other portion of the ovum has been left behind. It has 
also been found to occur after the removal of polypi, the enucleation of 
fibrous tumors, and the operation of lithotomy. In another class of cases, 
to adopt the classification of Dr. Tilbury Fox, it may be met with as part 
of a general disease. Under this head he includes those instances in 
which it has been developed as one of the distressing phenomena of puer- 
peral fever ; and, occasionally, in cases of ordinar}'- continued fever, a 
similar complication has been found to arise. With this variety are 
ranged three cases in which it was observed to coexist with dysentery, 
erysipelas, phthisis, and what Dr. Humphry described as a " preternatu- 
ral coagulability of the fibrine of the blood." A considerable number 
of instances have been recorded in w^hich the disease has been associated 
with malignant growths, not in the pelvic region merely, Avhich we could 
more readily understand, but as affecting distant organs, such as the stom- 
ach or the mammary gland. In the third class of cases, still observing 
the classification of Dr. Fox, phlegmasia dolens is met with as compli- 
cating other local diseases ; and under this head are ranged, and all on 
sufficient authority, examples of iliac abscess, suppressed menstruation, 
haemorrhoids, hepatic disease, and dislocation of the shoulder. It has 
also been observed in connection with pleurisy and pneumonia. These 
exceptional cases have, as we shall find, an obvious and important bear- 
ing on the hitherto obscure pathology of the affection. 

Symptoms. — As in most other diseases, the violence and typical dis- 
tinctness of the symptoms of phlegmasia dolens vary considerably ; and 
in some cases they are so feebly marked, that we have difficulty in 
determining whether the case should ' be classified under this head or 
should be considered as a simple case of oedema. In an ordinary case, 
40 



626 PHLEGMASIA DOLENS. 

the symptoms may either come on suddenly, when they are often 
ushered in by a rigor of some severity, or they may manifest themselves 
more insidiously, when certain premonitory signs are frequently noticed. 
These are, generally,- — in the puerperal variety, to which we shall in 
future exclusively refer, — a feeling of weight and discomfort in the 
hypogaster, extending round the brim of the pelvis, which is soon re- 
placed by actual pain, accompanied Avith more or less of constitutional 
disturbance. The pain is commonly referred more particularly to the 
inguinal region on the side which is about to become the seat of the 
disorder. We have more than once noticed that pain is complained of 
in the region of the hip-joint ; but, as this is not mentioned by other 
writers on the subject, we infer that the occurrence is exceptional. Dr. 
Denman describes, as a premonitory symptom, that '' before the appear- 
ance of any swelling, or sense of pain in the limb about to be aifected, 
women become very irritable, with a sense of great weakness, and 
grievously oppressed in their spirits, without any apparently sufficient 
reason ; complaining only of transient pains in the region of the uterus, 
and from these the approach of the disease has frequently been fore- 
told." The pain commencing, as has been described, in the inguinal or 
pelvic region, extends downwards, and, as the various districts of the 
thigh and leg become successively invaded by it, the swelling of the 
limb steadily advances in the same direction, until, at the height of the 
disease, the whole limb presents the Avhite, glazed, and sometimes enor- 
mously swollen condition which is so eminently characteristic. This is 
further accompanied by a complete loss of power, the patient being 
quite unable to move the limb, or indeed to change her position in bed 
without assistance. The tissues are tense and elastic, but, although they 
yield before the finger, they do not pit on pressure after the swelling has 
assumed its characteristic appearance. The temperature of the limb is 
usually increased. 

Notwithstanding the great swelling of the limb, the veins can gene- 
rally be distinctly felt, hard and rolling under the finger like a thick 
cord. This is more particularly the case in regard to the femoral vein, 
which may often be traced from the groin downwards, although the 
pressure gives rise to considerable pain. The swelling in some cases 
extends to the hip and vulva. The glands of the groin participate in the 
irritation, and sometimes become affected with well-marked inflammatory 
action, although they very rarely suppurate. The action obviously ex- 
tends to the lymphatics, and sometimes the only appearance, which varies 
the surface of the white limb, is a faint red streak here and there, indi- 
cating the situation of the affected vessels. A similar appearance, which 
in this case is more difi"used, has also been observed over the course of 
the venous trunks. It was first remarked by Dr. Stokes, — an observa- 
tion which has been corroborated by Dr. Churchill, — that the amount of 
the swelling is no proof of the severity of the disease ; but that, on the 
contrary, " the severity of the constitutional symptoms is often inversely 
as the swelling of the limb." 

In a certain number of cases, the symptoms run a somewhat different 
course. Obviously, in the instances referred to, the disease does not 
originate in the pelvis, and is ushered in by no such preliminary pelvic 



SYMPTOMS.^ 627 

symptoms as have been described above. " Sometimes," says Burns, 
" there is no uneasiness in the belly, and the first symptom is sudden 
pain in the calf of the leg. Within twenty-four hours after the pain is 
felt, the limb swells and becomes tense ; it is hot, but not red — it is 
rather pale, and somewhat shining." It is a matter of considerable 
importance that the peculiarities of this variety, which is by no means 
uncommon, should be borne in mind ; for otherwise the idea of " crural 
phlebitis," which has been very commonly supposed to express the pathol- 
ogy of the disease, might altogether divert our attention from symptoms 
which are nevertheless identical in all important particulars with those 
which are truly characteristic of phlegmasia dolens, the only difference 
being that in the cases which we are here considering, the disease begins 
below and thence extends upwards. 

The constitutional symptoms are just such as one might anticipate from 
a local affection of such importance. The lochial and lacteal secretions 
are either arrested or modified, and in the case of the former, the dis- 
charge sometimes becomes offensive. The degree of the fever is indi- 
cated by the frequency of the pulse, wdiich is seldom under 120. The 
complete loss of appetite, the furred tongue, and the state of the evacua- 
tions, all show how much the gastro-intestinal functions are disturbed. 
The patient is restless, sleepless, and complains much of thirst. 

After a time, which varies much in different cases, all the symptoms 
undergo an improvement. The fall of the pulse, and the subsidence 
generally of the constitutional symptoms, are accompanied both by relief 
of pain and a diminution of the sw^elling of the leg. A remarkable 
change now takes place in the character of the swelling, as it is no longer 
elastic and resistant, but pits on pressure like ordinary oedema ; and this 
change is sometimes observable before there is any very marked differ- 
ence in the size of the leg. The loss of power in the limb most marked 
in cases where the swelling has commenced at the groin, is often very 
persistent, and is one of the last symptoms to yield. We may expect, 
therefore, occasionally to meet with cases in which, in the absence of all 
evidence of constitutional disturbance and apparently of local change, 
this paralyzed condition of the leg remains for months and even for years. 
In some cases of exceptionally long continuance of immobility, there re- 
mains a permanently thickened condition of the tissues, which may some- 
what increase the circumference of the limb. In most cases, the ordinary 
sensibility of the leg is affected for a considerable time, and the patients 
often complain of what Dr. Churchill graphically describes as a wooden 
feel, which may persist in a degree for a long period. K varicose con- 
dition of the veins has been sometimes observed after phlegmasia dolens, 
which has been supposed by some to be due to a special morbid con- 
dition. 

But, w^hile the great majority of cases thus end in resolution, and ulti- 
mately in satisfactory although possibly tardy convalescence, it is not 
always so. For, in a few, suppuration occurs, in the limb itself, in the 
inguinal glands, or within the pelvis, in which latter case it may be dif- 
ficult to say which is the primary and which the secondary disorder. 
As the result of such suppuration, and, in some very rare instances, of 
gangrene, the exhaustion is so great that the patient succumbs ; but so 



628 PHLEGMASIA DOLENS. 

uncommon is such an event that the opportunities which have been 
afforded for the examination of the white leg after death are extremely 
rare. Let us see, however, what are the facts which morbid anatomy 
has disclosed. 

" On opening the limb," says Churchill, " it is found to be distended 
with serum, effused into the cellular membrane." This assertion is no 
doubt correct, but it is incomplete, and, being so, is apt to lead to an 
erroneous assumption. The words quoted will serve equally well for the 
description of what is observed when we cut into a part distended by 
ordinary oedema ; but the symptoms already detailed show one thing at 
least very clearly, that phlegmasia dolens is something essentially dif- 
ferent from oedema. It has been found, moreover, that the fluid which 
exudes in the latter condition is watery in its nature : but carefully ob- 
served facts have shown that the limb, and especially the fibro-cellular 
and cutaneous tissues, are distended, in phlegmasia dolens, with a pecu- 
liar serosity which is more or less coagulable. Again, thrombosis or 
plugging of the venous trunks of the limb, usually in the neighborhood 
of the groin, has been so constantly observed that it may be assumed as 
a phenomenon essential to the disease. This may exist with or without 
inflammation of the coats of the vessels. And, further, the great ma- 
jority of observers have noted that the lymphatics are also affected, their 
main trunks and more important glands often yielding evidence of inflam- 
matory action, which in the latter situation has occasionally gone on to 
suppuration. 

Fatliology. — The symptoms, morbid appearances, and even the varie- 
ties in nomenclature, all strongly point to one conclusion, — that the 
pathology of this disease has given rise to many differences of opinion, is 
in itself peculiar and perplexing, and remains, even at the present time, 
still somewhat obscure. It was at one time generally believed that the 
" white leg" was due to the presence of milk in the limb, and the idea 
was so far favored by the fact, that in most cases the lacteal secretion 
disappears. It is, however, somewhat surprising to find Puzos and 
Levret giving their countenance to an idea so absurd; for, although 
pathology in their days was still in its infancy, their assumption was far 
less advanced than the views of Mauriceau, who held, at a period seventy 
years earlier, an opinion which, indeed, comes pretty near some quite 
modern doctrines, when he describes the accident as one "which often 
succeeds pain in the ischiatic region, and is caused by a reflux — which 
takes place on those parts — of the humors which ought to be evacuated 
bv the lochia." The believers in this theory of a metastasis of the milk 
recommended that the child should be kept constantly to the breast. 

Towards the end of the last century, the subject attracted con- 
siderable attention in this country. Mr. White, of Manchester, then 
advanced the theory that the disease depended on obstruction, or on 
some other morbid condition, of the lymphatic vessels and glands of the 
affected part ; and subsequent writers suggested rupture of the lym- 
phatic vessels, or an inflammatory condition of the same parts, as the 
morbid lesion to which the familiar phenomena of the disease were, at 
least primarily, to be attributed. The opinion adopted by Dr. Hull was, 
that phlegmasia dolens consists "in an inflammation of the muscles. 



PATHOLOGY. 629 

cellular membrane, and inferior surface of the cutis, extending, in some 
cases, perhaps, to the large bloodvessels, nerves, lymphatics, and glands." 
This, which was sarcastically called by Davis, " Dr. Hull's capacious 
theory," indicates a belief that the disease is due to inflammatory action, 
but it otherwise throws no light upon the subject. Up to this time, no 
suspicion seems to have been entertained as to the part which the veins 
take in the production of the symptoms. The priority of publication on 
this subject is due to M. Bouillard, who, about the end of 1822, related 
several cases and dissections — which were shortly afterwards published 
in the " Archives Generales" — in which the crural vein was obliterated, 
and in regard to which he expressed a belief that the peculiar symptoms 
of this disease were due to obstruction of the venous trunks. Several 
years before this, the attention of Dr. Davis had been particularly 
attracted to this subject, in consequence of the death of a patient of his 
from phlegmasia dolens, but his essay was not published till some months 
after the date of M. Bouillard's communication. 

In the case in question, a very careful dissection wa,s made by Dr. 
Davis, assisted by Mr. Lawrence, in the course of which it was demon- 
strated that " the femoral veins, from the ham upwards, the external 
iliac, and the common iliac vein as far as the junction of the latter Avith 
the corresponding trunk of the right side, were distended, and firmly 
plugged with what appeared a coagulum of blood. The femoral portion 
of the vein, slightly thickened in its coats, and of a deep red color, was 
filled with a firm bloody coagulum, adhering to the sides of the tube. 
The trunk of the profunda was distended in the same way as that of the 
femoral vein ; but the saphena and its branches were empty and healthy." 
Ultimately, Dr. Davis advanced the theory that phlegmasia dolens is 
essentially Crural Phlebitis^ and under this name, as a synonym, the 
affection was till quite recently described by English writers. 

Although, for a time, the authority of Dr. Davis, supported by the 
corroborative testimony of Dr. Robert Lee and others, seems to have 
checked further inquiry, and to have resulted in a general relief, that 
what had been for so long a physiological problem was at last solved, 
many of the best pathologists were still dissatisfied with the phlebitic theory, 
and we believe with good reason. Virchow was one of the first to point 
out — what has since received ample corroboration — that, in phlegmasia 
dolens, inflammatory changes in the vessels may be altogether absent. 
In other words, thrombosis is not necessarily preceded, although it may 
be followed, by inflammation of the coats of the vein where the obstruc- 
tion has taken place. In this country, Dr. M'Kenzie took a prominent 
part in opposition to the views which were generally admitted. In the 
course of a very painstaking investigation of the subject, conducted, to 
a great extent, in the form of experiments on the lower animals, the in- 
ferences which he ultimately drew from his labors were as follows : "1. 
That inflammation of neither the iliac nor femoral veins would account 
for, or give rise to, phlegmasia dolens ; 2. That the extensive obstruction 
of the veins met with in this disease is not producible by merely local 
causes, such as injury or inflammation of these vessels ; 3. That, irrita- 
tion of the lining membrane of the veins, independently of such local 
injury or inflammation, will only give rise to obstruction of these vessels, 



6B0 PHLEGMASIA DOLENS. 

to an extent commensurate with that of the irritation which may have 
been excited within them ; 4. That extensive irritation of the lining 
membrane of veins, giving rise to obstruction and all the phenomena of 
phlebitis, may be excited by the presence of various unhealthy matters in 
the blood circulating with this fluid, and determined upon particular por- 
tions of the venous system ; 5. That the origin of the disease is therefore 
to be sought for rather in a vitiation of the circulating fluid than in any 
local injury, inflammation, or disease of the veins." 

Mr, H. Lee also performed a series of experiments conducted on a 
somewhat similar principle. His observations were meant to show, and, 
in point of fact, did clearly show, that it is by no means an easy matter 
to excite inflammatory action in the lining membrane of veins, even 
although irritant or septic substances be introduced into the veins and 
brought directly into contact with their lining membrane. These results 
are in perfect harmony with those which, quite independently, were ob- 
tained by Dr. M'Kenzie. Experiments wore also devised by the latter 
with the view^ of determining the eifect of irritation on the external coats 
of the veins ; and, although he injured and irritated their coats in various 
ways so as to excite localized inflammatory action, he found that such 
inflammation showed little tendency to spread, and that the lining mem- 
brane remained free from any effect arising from the irritation applied to 
the external parts of the vessel. Dr. M'Kenzie quite admits that coagula- 
tion of the blood contained in a vein is one of the phenomena of true 
phlebitis ; but he insists, and, we think, proves, that changes in the 
blood, due to septic action, may produce thrombosis with equal certainty. 
The effect of an admixture of pus in precipitating the fibrine is clearly 
demonstrated in the following experiment, which is one of those performed 
by Mr. H. Lee : " Some blood was drawn from a healthy horse, and 
poured into three vessels capable of containing three ounces each. The 
blood in the first vessel was allowed to remain as a standard of compari- 
son. To that in the second vessel was added some viscid matter from 
an indolent tumor in the horse's neck ; to that in the third, some pus 
from a chronic abscess. The contents of the third vessel (blood and 
pus) began to coagulate in three minutes; the mass was firm in four. 
In eight minutes the contents of the first and second vessel had become 
firm." 

Dr. Tilbury Fox, in two very able papers communicated to the Ob- 
stetrical Society of London in 1861, and published in their Transactions 
for that year, enters very fully into the subject, and strongly opposes 
the view that phlebitis is an essential phenomenon of phlegmasia dolens. 
His leading idea is, that the cause of the peculiar phenomenon of white 
leg "is an impediment to the return of blood and lymph from the affected 
part ;" and he goes on further to observe, " that the causes of such im- 
pediment may be, so far as regards the vessels, extrinsic and intrinsic^ 
The extrinsic causes comprise all cases of pressure on the vessels from 
tumors, abscess, etc. The intrinsic causes, again, are all assumed to 
produce coagulation, and the more important of these are: 1. Phlebitis, 
septic or non-septic ; 2. Introduction of morbid matter into the vein, pro- 
ducing simple thrombus, but not phlebitis; 3. Preternatural coagulability 
of the fibrine of the blood, as assumed, and, in a manner, proved by Drs. 



PATHOLOGY. 631 

Humphry and Graily Hewitt. While not denying the possibility of 
crural phlebitis being associated with, or even preceding the phenomena 
of phlegmasia dolens, Dr. Fox argues, with much force and ability, in 
favor of the conclusion that a septic action proceeding from the denuded 
inner surface of the uterus is the most probable cause of the disease. 
With reference to this he writes as follows : — 

'' It can in no wise be denied that the parturient woman is a subject 
apt for the occurrence of thrombus; there is hyperinosis, the uterus 
offers a denuded stop (stump?), its veins are thin, osmosis is easy, the 
lymphatic act and circulation are active in removing the disintegrating 
uterus in conjunction with the veins, etc. These constitute an analogous 
condition to that stage in w^iich phlegmasia dolens is w^ont to occur 
elsewhere, — I mean the ulcerative stage and kind of disease, e. g., dys- 
entery, cancer, phthisis, — so much so that we should not expect it to 
occur when wound is absent, except from extrinsic pressure. This close 
relation of wound in the one case — phlegmasia dolens, — and the absence 
of it in the other — oedema, is a contrasting difference in the pathology of 
the two states ; in other words, where wound is, the lymphatics are in- 
volved. Now for the culminating point, — the cause of the rapid absorp- 
tion. I have been particularly struck, in the cases that have come under 
my notice from the outset, by the occurrence of notable hemorrhage, or 
profuse discharge of other kind ; and I find, from close inquiry, that the 
reminiscence of the practice of others, well able and qualified to give an 
estimation of the point, affords the like result. I have been desirous for 
some time to ascertain if there be any relation between the two phenom- 
ena — discharge and phlegmasia dolens. My belief is, that the cases 
which cannot be accounted for by the existence of phlebitis or pressure, 
are due to simple coagulation, the result of tolerably rapid absorption of 
morbid fluid ; this excess of absorption, over and above what is natural, 
being induced by the occurrence of notable sudden discharge, — the latter 
being the culminating point in the causation. We do find present facility 
for rapid absorption, wound, and morbid fluid, in the cases in which 
phlegmasia dolens, of the type under discussion, occurs. Of course, this 
is at issue with Dr. Humphry, who, in his pamphlet, says that there cer- 
tainly seems no reason to attribute the affection to an introduction of 
pus, or other morbid fluid, into the circulation. "^ 

Dr. Fox sums up his conclusions, with reference to the disease under 
consideration, as follows : " Prop. I. In phlegmasia dolens both veins and 
lymphatics are obstructed. Prop. II. The obstruction may be due simply 
to extrinsic pressure. Prop. III. Or to inflammatory changes in the 
coats of the vessels, leading to coagulation. (This depends upon virus 
action.) Except during epidemics of puerperal fever, this is not so com- 
mon as supposed. Prop. IV. It is pretty well admitted that rapid 
ingress of abnormal fluid, suddenly, and in large amount, will cause in- 
stantaneous coagulation of the blood ; and it is also admitted that large 
drains from the system are followed by rapid and compensating absorp- 
tion. There is good reason for believing that these conditions are 
fulfilled, in a perfect and ample degree, in conjunction with the presence 

1 " Transactions of the Obstetrical Society of London." 1861. 



632 PHLEGMASIA DOLENS. 

of wound, — facilitating absorption, — in a great many cases prior to the 
occurrence of phlegmasia dolens, and that the latter is frequently thus 
evolved. Prop. Y. These different modes of evolution may be more or 
less conjoined." 

On a review of the whole subject, and setting aside such of the older 
theories as are clearly incompatible with the possibilities of modern 
pathology, we cannot but admit that phlegmasia dolens is still a matter 
in regard to which we have something to learn. That thrombosis of the 
venous trunks, from whatever cause arising, is essential, we do not 
question ; but it is clear that this will not account for the phenomena 
which we observe, since the symptom which, above all others, is held to 
be indicative of an obstruction to the venous return, — oedema, to wit, — 
is, during the active stage of the disease, absent. Nor do we believe 
that the simple theory of phlebitis can be accepted as a solution of the 
problem, in so far, at least, as this may be considered the proximate 
cause of the disease. No one can dispute that phlebitis causes coagula- 
tion of the blood contained in the affected vein. In those cases of phleg- 
masia dolens in which the affection has been associated with the more 
serious varieties of puerperal fever, clear evidence of inflammation of the 
coats of the veins has been observed ; and the theory referred to has 
received still further corroboration from the observation of Dr. Robert 
Lee, who traced such venous inflammation to its most probable source, in 
the uterine branches of the hypogastric vein. 

But, on the other hand, it has been satisfactorily demonstrated, both 
by Dr. M'Kenzie and by Mr. H. Lee, that the veins, and especially their 
lining membrane, are singularly averse to taking on inflammatory action ; 
and it has also been shown, with almost equal certainty, that the deeper 
color of the membrane referred to is not a necessary indication of inflam- 
mation, but is due rather to the action of the coloring matter and the 
contact of the clot. But, were we even to admit that phlebitis is an 
essential part of the disease now under discussion, there is no suffi- 
cient evidence that the one condition depends upon the other. If we 
study the description given by surgical pathologists of the affection 
known as "fibrinous phlebitis," with which alone phlegmasia dolens can 
fairly be compared, we find that, among the more important of the symp- 
toms which are detailed, swelling of the limb below the affected part and 
oedema of the surrounding cellular tissues are among those which are 
most prominently put forward. In no single case, so far as we know, 
since M. Breschet first demonstrated and named the affection, has phle- 
bitis been described as involving, in the case of a limb, the white, elastic, 
painful, and benumbed condition which is so diagnostic of the other 
disease. We do not hesitate, therefore, to reject the term " crural 
phlebitis" as synonymous with phlegmasia dolens. 

While giving every weight to the authority of such names as Denman, 
Caspar, and Dewees, we confess that the theory with which their names 
are associated is even less satisfactory than the other, for were we to 
admit that angeioleucitis may account for the appearance and character 
of the swelling, this affords no explanation whatever of the fact that the 
veins are plugged with clots. We may indeed be perfectly sure that to 
them the fact last mentioned was unknown ; for had it been brought 



PATHOLOGY. 633 

under their knowledge it could scarcely have failed to prove to them 
that, even if, as Denman said, " the glands and lymphatics of the limb 
were evidently the parts first and primarily affected," there was some- 
thing more than this necessary to account for the phenomena ordinarily 
observed in these cases. What has already been explained in reference 
to the symptoms of the disease, and the attendant morbid conditions, cer- 
tainly proves that, in some cases at least, the vessels and glands of the 
lymphatic system are involved ; but probably no one will now attempt to 
maintain that an inflammation of these structures will, if uncomplicated, 
account for the white leg of the puerperal state. 

On the whole evidence, we are of opinion that the first crude theory 
of Mauriceau points significantly in the direction to which we may most 
confidently look for a solution of the difficulties which beset the subject. 
We do not of course mean that his quaint idea of a " reflux of humors" 
from the womb upon the limb was, in the sense wiiich he attached to the 
expression, a pathological speculation which modern experience could 
justify ; but rather that, in thus pointing out a possible connection be- 
tween a local lesion and a septic action, starting as in other analogous 
cases from the wound, he indicated, in a striking manner, the direction 
in which we should seek for a solution of the problem. There is abundant 
evidence to prove that septic agents of various kinds may cause coagula- 
tion of the blood. The experiments of Mr. H. Lee, already alluded to, 
showed that pus produced this effect. Dr. M'Kenzie ligatured the left 
femoral vein of a dog and injected half an ounce of a solution containing 
lactic acid. The animal died in half an hour, and on examination it w^as 
found that " the iliac veins on the left side from the femoral up to the 
cava, and a considerable extent of the cava, Avere obstructed by what 
appeared to be a firm coagulum ; and on opening these vessels this was 
found to be closely adherent to their lining membrane." An exceedingly 
interesting case bearing on the same point is given by Dr. Tilbury Fox, 
of a lad aged twelve years, who, being bitten in the thumb by an adder, 
presented next day " a perfect and complete specimen of phlegmasia 
dolens" in the affected limb, so that we may assume that coagulation had 
been at least one of the results of the poison which was introduced in the 
manner described. 

On the whole, therefore, we think that the preponderance of evidence 
is in favor of the idea that, in most cases of phlegmasia dolens, there is 
a precipitation of the fibrine by the action of some septic agent which has 
made its way into the blood, or has been developed in that medium. In 
this sense, Yirchow's theory, " that the first pathological condition is the 
formation of a clot in the vein," may be accepted as highly probable. 
Certainly this is more likely than that true phlebitis is essentially the 
proximate cause, although no one can dispute either that phlebitis may 
cause coagulation, or that inflammation of the vein tissues may accom- 
pany the other and more essential phenomena of phlegmasia dolens. It 
may obviously, and with perfect propriety, be urged against this theory 
that a septic action having its origin in a wound cannot apply to those 
cases in which the symptoms of undoubted phlegmasia dolens manifest 
themselves unconnected with the pregnant state. But we cannot see 
that this must necessarily be admitted as a serious difficulty ; for, if the 



634 PHLEGMASIA DOLENS. 

proximate cause of the disease is assumed to be a septic action proceeding 
in a great majority of cases from a recently denuded surface, it is surely 
not too much to assume that, in exceptional cases, the septic action which 
leads to coagulation may proceed from intrinsic causes, or even from 
poison introduced in some other way from without, as in Dr. Tilbury 
Fox's case above alluded to. 

It is, however, impossible to avoid the conclusion that a septic action 
and the resulting coagulation cannot satisfactorily account for all the 
phenomena of the disease. All that is necessarily involved in such an 
hypothesis is mechanical Obstruction in a venous trunk, from which we 
could only anticipate oedema as a direct result. To the development, 
therefore, of the white elastic swelling something more is required ; and 
this forces upon our notice the inquiry as to what are the auxiliary or 
supplementary conditions referred to. 

No modern writer on the subject ventures to advocate the theory, which 
at one time had the support of the most distinguished obstetricians of the 
age, that the seat of the disease is essentially in the absorbent or lym- 
phatic system. The facts demonstrated with reference to the veins pre- 
clude such a belief. But it by no means follows that the absorbent sys- 
tem takes no share in the development of the symptoms alluded to. The 
red strea^ks occasionally observed over the course of the larger lymphatic 
vessels, and the exceptional occurrence of inflammation and suppuration 
in the glands, prove quite clearly that they may be involved. But there 
are other considerations which seem to indicate something more than this, 
and that an aifection of the lymphatics is an essential, although, proba- 
bly, a secondary part of a typical case of phlegmasia dolens. If we 
assume, as some of the most distinguished of modern pathologists have 
done, that the lymphatic system affords the channel through which fibrine is 
introduced into the blood, we can readily understand why an obstruction 
in the vessels of that system, whether inflammatory in its nature or purely 
mechanical, may cause many of the essential phenomena of the disease. 
Plugging of a venous trunk could but cause oedema ; but venous obstruc- 
tion, j9?^*s an impediment to the circulation in the lymphatic system, may 
quite readily be assumed to cause symptoms very like those which we 
have already described. "If there be any relation," says Dr. Fox, 
" between the lymphatic fibrine and the cellular tissue, it is easy to un- 
derstand how obliteration of the lymphatics may give rise to the peculiar 
character of phlegmasia dolens, on account of the retention of the fibrin- 
ous material in the tissues — the cellular especially, which is so rich in 

lymphatics The cellular tissue itself seems to be hyper- 

trophied, the lymph also gelatinizing in its interstices." 

The marked loss of power in the affected limb, out of all proportion to 
the mere amount of swelling, and which is, as we have seen, frequently 
of long continuance, seems, at one time, to have led to the idea that the 
nerves were primarily involved ; and M. Duges has certainly shown that, 
in some cases at least, inflammation of the nerves and of their sheath 
occurs. It seems to us, however, that serious lesion of the nervous 
trunks is, even from a purely theoretical point of view, by no means 
necessary to the temporary paralysis so characteristic of the disease. 
All, in fact, that is necessary to the arrestment of the nervine functions 



TREATMENT. 635 

is pressure ; and, in the condition to which the parts are reduced in the 
rapid development of a tense swelling, we may be sure that the nerves 
can scarcely escape such pressure as may produce the effect to which we 
refer. 

The confusion wdiich has so long prevailed in regard to the pathology 
of phlegmasia dolens seems to have been due, in a considerable degree, 
to the obstinacy with which pathological theories were pinned to affections 
of the individual tissues or textures. No such theory can, as it seems 
to us, satisfactorily account for what, in these cases, we observe. It is, 
no doubt, of great interest to determine, if w^e can, what part, or parts of 
the animal economy are primarily involved ; but we may be quite sure that, 
if we take up any exclusive theory, as to the disease being one of a single 
fluid or a single texture, we pass into a field of speculation wdiich is little 
likely to lead us to the truth. Doubtful though many points in regard to 
its pathology may be, we have no difficulty in refusing to admit of Crural 
Phlebitis, or Angeioleucitis, as terms which represent the true nature of 
phlegmasia dolens. Either of these conditions may, no doubt, exist ; 
but if it be so, they are secondary rather than essential. Thrombosis, 
or obstruction otherwise to the venous return is apparently essential ; and, 
in so far as the absorbents are concerned, it is possible that Dr. Tilbury 
Fox is correct in assuming that a similar obstruction is produced in them. 
But, as regards the latter, no plugging of lymphatic trunks has ever, in 
so far as we are aware, been demonstrated. Nor do we believe that it 
has been established that the disease is inflammatory in its origin, nor 
even that the inflammatory process is, at any stage, an essential patho- 
logical condition. On the contrary, we think that we perceive in the 
narrative of post-mortem appearances in fatal cases, another, and a very 
obvious source of error. That morbid appearances indicating inflamma- 
tory action have been frequently observed after death, we can well be- 
lieve ; but we must bear in mind that fatal cases are rare, and that, in 
ordinary cases, even when severe, there is rarely evidence, during life, 
of any such action. "VYe demur, therefore, to the conclusion, that in the 
morbid phenomena of exceptionally severe cases, we have a demonstration 
of these essential features of what we have called an ordinary or typical 
case. Inflammation, in fact, we take to be, whether it is observalDle in 
the veins, the absorbents, or the contiguous tissues, an exceptional and 
essentially a secondary occurrence. 

Treatment. — The fact that phlegmasia dolens follows in so large a 
proportion of cases upon a condition of debility and exhaustion, usually 
produced by hemorrhage, shows pretty clearly that the case is not one 
for an antiphlogistic regimen. This may be conceded even by those 
who believe most implicitly in the inflammatory nature of the disease ; 
and the opinion must necessarily gain strength if we assume that a 
septic action proceeding from, or associated with constitutional ex- 
haustion, is an essential part of the disease. A belief in the inflam- 
matory theory has not unnaturally led to a very general impression that 
blood-letting should usually be adopted. Few persons in the present 
day would probably think of general blood-letting, but it is commonly 
taught that leeches should be applied over the course of the affected 
vein ; and, indeed, the rules for treatment which are laid down by many 



636 PHLEGMASIA DOLENS. 

writers on the subject are such as to convey the impression that leeches 
are applicable to all cases. Such an idea is, of course, at variance with 
the view which we have expressed as to the nature of the disease, and 
cannot, certainly, be admitted as a safe guide to judicious treatment. 
The cases, in fact, to which the application of leeches is advisable are 
those only in which there is evidence of a local inflammatory action, 
which may very readily be induced under such circumstances, either in 
the lymphatics or in some other of the tissues of the limb. But even a 
clear indication of true inflammation does not necessarily warrant deple- 
tion, for we must first — and this is the most important point of all — 
be sure that the affection has not sprung from debilitating causes, for, 
if it be so, to bleed is simply to encourage exhaustion, and to facilitate 
the absorption of septic materials. Blood-letting, then, we believe to 
be applicable to that comparatively rare class of cases only in which 
inflammation exists in the absence of constitutional exhaustion. 

Considerable benefit appears to have been derived in many instances 
from the application of blisters to the leg. Some have gone so far as to 
say that, in the treatment of this disease, blisters are to be regarded as 
specifics, but this is evidently a pardonable exaggeration. They may 
be applied, as we believe, with a reasonable prospect of success, in cases 
where there is inflammation, and where the general condition of the 
patient prevents us from having recourse to blood-letting, and there is 
certainly one effect upon which we may count with some confidence—- 
that being a cessation, or at least an alleviation, of the pain which is so 
characteristic a feature of the more severe examples of the disease. 
Otherwise, the only effect which is likely to be derived from this method 
of treatment differs in no respect from that which, under similar con- 
ditions, we anticipate from the action of counter-irritation of any kind. 
Probably, Dr. Churchill is quite correct when he says that, although his 
own experience is decidedly in favor of the utility of blisters, "in many 
cases turpentine fomentations will answer equally well." 

Bandages, if judiciously employed, are extremely useful in the cure 
of phlegmasia dolens. To the early stage, while the sweUing is rapidly 
being developed, firm bandaging is for obvious reasons inapplicable, and 
might very possibly be attended with further arrest of the circulation, 
and sloughing similar to what has occasionally occurred from careless or 
unskilful bandaging in surgical practice. What is at this period safer 
and more judicious is to swathe the limb in fomentations, which, if 
the pain be severe, may be sprinkled with laudanum. On the subsi- 
dence of the more acute symptoms, bandaging may always be resorted 
to, at first with flannel and subsequently with an ordinary roller band- 
age. What may be safely held as indicating the period at which band- 
aging is proper, is when the limb pits on pressure, this pitting being 
probably impossible until the permeability at least of the lymphatic 
trunks has been restored. 

Certain facts which have been observed with reference to the progress 
of these cases have suggested a suspicion that, in its more severe varieties, 
or, it may be, under exceptional circumstances, the affection may be prop- 
agated by contagion. That it may be so, when associated with the 
more serious phenomena of puerperal fever, we can readily believe ; but 



TREATMEXT. 637 

we do not think that there is any evidence which would lead us to sup- 
pose that an ordinary case is thus communicable. The assertion has, 
however, been made upon high authority, and it will thus be well, even 
should the precaution be deemed superfluous, to take such means as may 
render any propagation of the disorder in this manner as little likely to 
occur as may be possible. 

From what has already been said, it may be inferred that the con- 
stitutional treatment applicable to phlegmasia dolens is to be adapted far 
more frequently to a state of general debility than to a sthenic condition 
requiring antiphlogistic remedies. We speak, of course, of such cases 
as present the features of an ordinary puerperal case ; but we do not 
mean to deny that exceptional treatment may be absolutely requisite to 
the proper management of particular cases, where marked local inflam- 
mation and accompanying fever of the sthenic type may call for prompt 
and energetic action. The state of the bowels must be carefully attended 
to, and, although it will rarely be advisable to give strong purgatives, it 
is almost always necessary to regulate the discharges by gentle laxatives 
or enemata, and to maintain them otherwise in a healthy condition. 
Should the lochia become in any degree offensive, weak carbolic injec- 
tions may be thrown into the vagina once or twice a day in the usual 
way. From a very early period of the case, the diet must be generous, 
and it will often be deemed expedient to give beef-tea or stronger soups, 
and even wine from the first. During the period of convalescence, a 
similar method of treatment must be persevered in. 

A tonic regimen being thus clearly indicated, it is often found neces- 
sary to administer iron, quinine, and other tonics. Dr. M'Kenzie, with 
the view of neutralizing any septic materials which may exist in the 
blood, recommends the administration, either of hydrochloric acid, or of 
the sesquicarbonate of ammonia in full, concentrated, and frequently re- 
peated doses. He directs that "an ounce of hydrochloric acid should be 
taken daily in a quart of barley or plain water, sweetened with syrup of 
ginger, and flavored with lemon peel." 

It is by no means a rare occurrence that, in cases of this affection, 
quite unconnected with pelvic abscess or any other secondary affection, 
convalescence is extremely protracted. This, no doubt, depends chiefly, 
and in many cases entirely, on the effect which has been produced upon 
the nerves, resulting, in extreme cases, in actual paralysis of the limb. 
To the treatment of this condition, stimulating frictions are suitable, and 
it has also been recommended that, at this stage, a succession of small 
blisters be applied over the limb at various parts. Nothing is better, in 
such cases, than tepid sea-bathing, and especially the salt water douche, 
followed by friction of the parts. There is good reason to believe that, 
in some instances of slow recovery, this is due to the permanent plugging 
of the venous trunks, or possibly to their obliteration as the result of 
inflammatory action. In this case, as after deligation of arterial trunks, 
it may be some time before an efficient collateral circulation is estab- 
lished, and the functions of the parts are thus but feebly discharged. It 
is much more probable, however, that changes take place in the clot, 
which ultimately result in the restoration, partial or complete, of the cir- 
culation within the vessel. " The blood," says Murphy, "has the power 



638 PUERPERAL INSANITY. 

of separating from itself a fibro-albuminous element without the inter- 
vention of any membrane, and independently of any inflamed surface. 
Through this medium, the coagulum becomes adherent to the sides of the 
vein (as in the old aneurismal sac) ; and if it be attached to the whole 
circumference, the inner portions become softened and broken down. A 
complete cylinder of fibrine may in this way be formed in the interior of 
a vein, through which (when the fluid portions of the coagulum are re- 
moved) the blood will circulate." We need scarcely wonder, then, that 
the results of treatment are often unsatisfactory, and convalescence pro- 
portionally tardy. 



CHAPTEE XLI. 

PUERPERAL INSANITY. 

Nomenclature. — Normal Effect of Pregnancy on the Mind. — Insanity associated 
ivith pregnancy, Labor, or Lactation. — True Puerperal Insanity. — Pathologi- 
cal Theories. — Connection of Puerperal Insanity with Albuminuria. — Puek- 
PERAL Mania ; to be distinguished from Phrenitis : is essentially a Disease of 
Exhaustion. — Symptoms: Significance of a rapid Pulse : Violence: Delusions. 
— Prognosis. — Puerperal Melancholia : Distinguishing Characteristics : 
Probable Terminations. — Treatment : Prevention : Blood-letting to be avoided : 
Management of, the Digestive Functions : Emetics : Vascular Sedatives : 
Nervous Sedatives; Opium, Hyoscyamus, Chloral, ^c. : Diet and Regimen: 
Seclusion and Restraint : Treatment during Convalescence. — Tendency to Re- 
currence after Subsequent Labors. 

The terra Puerperal Insanity is here chosen in preference to the more 
familiar designation of Puerperal Mania, for the obvious, and, we think, 
very sufiicient reason, that the forms under which mental aberration may 
occur, in the puerperal state, are various, and the proportion of cases in 
which the symptoms are of such a nature as to fall under the category 
of Mania, is by no means so overwhelming as to justify the exclusive use 
of that name. 

It requires no very close observation of pregnancy and the puerperal 
state, to discover that the mental as well as the bodily functions are, in 
a very considerable proportion of all cases, disturbed. The psychologi- 
cal phenomena to which we here refer, far from being symptomatic of 
mental unsoundness, or what we call insanity, are indicative merely of 
the presence and operation of some disturbing influence, dependent, 
doubtless, upon the condition in which the woman is placed. For ex- 
ample, it is by no means an uncommon thing — as we had occasion to 
notice in connection with the Signs of Pregnancy — for the temper of the 
woman to be changed for the worse during the course of a pregnancy. 
She becomes fretful, capricious, and, in many indescribable ways, different 



PUERPERAL INSANITY. 639 

in temperament and disposition. Further, the emotional faculties are 
sometimes less under control, when causeless tears or laughter indicate an 
hysterical disposition ; and, in other cases, the organs of special sense, 
and especially those of taste and smell, are strangely perverted, in a 
manner which every practitioner has had opportunities of witnessing. 
We may, therefore, venture to assume that this psychological sensitive- 
ness can scarcely fail, when it exists, in some degree to predispose to a 
paore serious disturbance of the mental faculties. 

Mental alienation, associated with the highest function of the genera- 
tive organs, occurs under a variety of circumstances. It may thus mani- 
fest itself during pregnancy, in the course of labor, during the puerperal 
state, or while the woman is nursing. The insanity of pregnancy is de- 
veloped, in the majority of cases, between the third and the seventh 
month. It is generally characterized by melancholia, or by moral per- 
version ; and the result of treatment is, as compared w^ith the other 
varieties, very satisfactory. What was described by Montgomery as the 
mania of labor, is rather a frenzy or temporary delirium, — the result, 
probably, of the agony which the woman suffers, or of temporary dis- 
turbance of the cerebral circulation. " It is not," he says, " accompa- 
nied nor followed by any other unpleasant or suspicious symptom ; it 
occurs, perhaps, after the patient has been talking cheerfully, and, hav- 
ing lasted a few minutes, disappears, leaving her perfectly clear and col- 
lected, and returns no more, even though the subsequent part of the 
labor should be slower and more painful. In every instance which came 
under my observation, the patients were conscious that they had been 
wandering, and occasionally apologized for anything wrong they might 
have said, although they were not aware of what the exact nature of 
their observations might have been." The insanity of lactation has been 
observed, in a very large proportion of cases, after the sixth month of 
nursing, — a fact which, along with the accompanying symptoms, points 
clearly to the conclusion that the disease is the result of debility, pro- 
ceeding from an injudicious prolongation of the period of nursing. It is 
more frequent in women over thirty years of age, and in those who have 
previously borne children, but especially so in those who have become 
repeatedly pregnant at short intervals. In this variety also, the insanity 
more generally assumes the melancholic than the maniacal type. 

Puerperal insanity is by no means of rare occurrence. According to 
Esquirol, about one-twelfth of the women admitted to the Salpetriere were 
clear examples of the disease, while among the more opulent classes 
the proportion was even higher, — nearly one-seventh. The statistics of 
the subject further teach us, that primipar^ are more liable than plu- 
riparse, and that the class of cases in which susceptibility to puerperal 
insanity is most marked, are those in which women between the ages of 
thirty and forty are confined for the first time. In a considerable num- 
ber, — it is said, indeed, in about a half of all cases encountered in prac- 
tice, — hereditary predisposition has been noted; and it would further 
appear that complicated and exhausting labors are much more frequently 
followed by insanity than those in which the course of labor has been 
normal. It was first pointed out by Esquirol, and the observation has 
been confirmed by others, that unmarried women, who feel deeply the 



640 PUERPERAL INSANITY. 

degradation of their position, are much more susceptible than others. 
These, then, in addition to the functional susceptibility which is so 
characteristic of the puerperal state, may be confidently admitted as pre- 
disposing causes. But, as regards exciting causes, and the pathology of 
the disease, there is little upon which we can rely. Cold, imprudence in 
diet, sudden mental shock, disordered bowels, and a number of other 
similar conditions, have been generally assumed as causes of puerperal 
insanity; but most of them, as it appears to us, on insufficient evidence. 

From a pathological point of view, the etiology of the subject is even 
more obscure. We may readily obtain, by observation, abundant evi- 
dence of the sympathy which subsists between the uterus and the cere- 
brum, and we need, therefore, scarcely wonder that attempts have 
occasionally been made to connect the mental disturbance with uterine 
lesion. But, although we may admit that a certain number of authentic 
cases have- been advanced on undoubted authority, and were we even to 
concede that metritis may apparently be the approximate cause of insanity 
in some instances, it is abundantly evident that, in the great majority of 
cases, no such cause exists. Other instances — to which the same obser- 
vation may apply — have been recorded, in which there was an apparent 
connection between the mental disorders to w^hich we refer, and ovarian 
or peritoneal inflammation. Some writers — among whom we may men- 
tion Burns and Davis — were of opinion that the disease was of inflamma- 
tory origin, and described it as a modification of phrenitis ; but modern 
experience thoroughly corroborates the view which was taken by Gooch, 
" that the disease is not one of congestion or inflammation, but one of 
excitement without power," — an opinion which derives most ample con- 
firmation from the narrative which he gives, in his admirable thesis on 
this subject, of eleven cases in which there could at no time have been 
any inflammation of the structures within the cranium. Dr. Ferrier sup- 
posed that the loss of reason, in most cases, was mainly due to some 
interference with the establishment of the function of lactation. 

One of the most interesting of modern speculations, with regard to the 
pathology of puerperal insanity, had its origin in a suggestion which was 
made by Sir J. Simpson, that there might be an essential connection 
between that disorder, and disease of the kidney, or at least the presence 
of albumen in the urine. That the disease may thus or in some other 
way have a toxeemic origin is, of course, perfectly possible ; and the 
theory has further a peculiar interest in connection with puerperal 
eclampsia, in which albuminuria is a phenomenon familiar to modern 
pathologists. Simpson's original suggestions on this subject, which were 
published in 1857, were based upon the observation of four consecutive 
cases, in all of which he found albumen present in the urine. His sub- 
sequent experience, with ample corroborative evidence from other sources, 
can leave little doubt in the mind that his first idea was correct, and that 
between the two conditions there probably exists an essential though in- 
explicable bond of association. It would appear that the presence of 
albumen is only indicated by the usual tests for a short time after the 
attack commences, and is, therefore, less persistent than in the case of 
convulsions. "The fire of disease goes on burning," says Simpson, "in 
these cases of insanity, after the lighted match is merely applied, and the 



ALBUMINURIA. 641 

strange morbid clockwork runs on, as it were, after the kej that wound 
it up is withdrawn. I have seen all traces of albuminuria in puerperal 
insanity disappear from the urine within fifty hours from the access of 
the malad}^ The general rapidity of its disappearance is, perhaps, the 
principal, or, indeed, the only reason why this complication has escaped 
the notice of those physicians among us who devote themselves with such 
ardor and zeal to the treatment of insanity in our public asylums." 

The same writer, wdule making no pretence of solving what all admit 
to be a pathological riddle, seems to think that the cause of this disease 
may hereafter be discovered by the patholoo;ical chemist to consist in 
certain changes in the renal secretion, involving, secondarily, chemical 
changes in the blood itself. One well-known effect, wdiich is apt to 
follow the appearance of albumen in the urine, is a diminution in the 
quantity of urea excreted. But, as Frerichs Las shown, the mere pre- 
sence of an excess of urea in the blood does not necessarily involve a 
septic action on the nervous system ; and the same able observer holds 
that the decomposition of urea, resulting in the formation of carbonate 
of ammonia, affords a satisfactory explanation of the intoxicating or 
poisonous effect which is produced through the blood upon the nervous 
centres in the case of puerperal eclampsia. x\nd it is, perhaps, not too 
much to assume that this theory, if correct in the case of convulsions, 
may equally apply to the phenomena of puerperal insanity. Simpson 
suggests further, in support of this theory, that the state of the blood is 
favorable to the occurrence of such decomposition as may be necessary 
to the formation either of the carbonate of ammonia, or of some other 
organic toxicological agent, possibly of an alkaloid character. '• In the 
blood of the puerperal female," he writes, — "greatly modified as it is 
in the normal states of pregnancy and delivery, and containing as it does 
after parturition the effete elements of the involving or disintegrating 
uterus, and the materials for the new lacteal secretion — ferments and 
agents may possibly exist which are more apt to develop special morbid 
poisons out of the retained renal excretions, than happens in other states 
of the system. But, I repeat, the whole subject is yet quite dark and 
conjectural, and will remain so till pathological chemistry is able to cast 
some light upon it." 

Dr. Donkin contributed a very excellent paper on this subject.^ 
Recognizing the fact that puerperal insanity may present itself under 
a variety of forms, he deduces from the history of recorded cases facts 
which appear to him to warrant the conclusion "that the acute dangerous 
class of cases are examples of ur^emic blood-poisoning, of which the 
mania, rapid pulse, and other constitutional symptoms are merely the 
phenomena ; and that the affection, therefore, ought to be termed 
uniemic or renal puerperal mania, in contra-distinction to the other form 
of the disease." Although no one is likely, in the present day, to agree 
with Dr. Donkin, his paper is replete with interest, and will well repay 
the trouble of perusing it. 

Dr. Fordyce Barker, in his recent work, asserts that, in a large 

' Edinbiirgli Medical Journal, Maj, 1863. 
41 



642 PUERPERAL INSANITY. 

number of cases of puerperal insanity which have come under his 
observation, he has found albumen associated with so small a proportion, 
that he finds himself compelled to regard it, when present, as simply a 
coincidence and not a cause. It is his firm conviction that the mental 
emotions constitute the exciting cause infinitely more frequently than all 
other causes combined, and he adduces very interesting statistical facts 
in support of his theory.' 

The form of puerperal insanity which is of most frequent occurrence 
is that in which the symptoms are commonly manifested within a 
fortnight after delivery, and present with greater or less distinctness 
the characteristic features of acute mania. It is to this alone — the 
paraphrosyne puerperarum. of Sauvages — that the designation " Puer- 
peral Mania" can with perfect propriety be attached. Of fifty-seven 
cases noticed by Burrows, thirty-five were maniacal, sixteen melancholic, 
and eight alternating; and, although the relative proportion of cases 
has varied according to the experience of various writers, all agree that 
the maniacal cases are greatly in excess of the others. This is, no 
doubt, the class of cases, the observation of which by the earlier writers 
on the subject gave rise to the idea that the violence of the symptoms 
was due to inflammation. It were absurd to deny that phrenitis is 
possible in lying-in women as in others ; but no one now questions the 
accuracy of the statement made by Gooch, "that furious delirium from 
inflammation of the brain is a rare disease in child-bed." What seems 
to have given, for a time, apparent confirmation to the inflammatory 
theory was the fact that, in fatal cases of puerperal mania, the brain 
was found congested. The experiments of Dr. Kelly upon the lower 
animals, and a host of pathological facts which have been put on record 
since his day, have conclusively proved to demonstration, what is familiar 
to every modern pathologist— that death from hemorrhage and other 
exhausting causes produces in the brain that very appearance of increased 
vascularity which, as we assume, was accepted by Burns, Davis, and 
others as evidence of inflammatory action. 

Although, therefore, we admit meningitis to be classed as a possible 
complication of the puerperal state, there is little likelihood of our 
diagnosis being obscured by such an occurrence. Qlie very early period 
of its accession after delivery, and the manifestation of headache, 
suff'usion of the eyes, and other local symptoms referable to the head, 
would doubtless indicate the nature of the disease to the judicious 
practitioner. But not only do we discard the idea of inflammation 
as pathognomonic of puerperal mania, but we embrace without hesita- 
tion a directly opposite view, that it is essentially a disease of ex- 
haustion. This is so far indicated by the fact already mentioned, that 
puerperal insanity in both its forms is more common after exhausting 
and operative cases, than when the progress of labor has been normal. 
It is further strongly corroborated by the details of treatment, in which 
we are not astonished to find that patients fainted after the abstraction 
of a few ounces of blood ; and by the experience of the most reliable 
modern authorities. 

' The Puerperal Diseases, by Fordyce Barker, M.D., New York, 1874. 



SYMPTOMS. 643 

The symptoms of puerperal mania do not differ in any very essential 
particular from those which are exhibited by patients who are the 
subjects of the same disease unconnected with the puerperal state. 
Still there are peculiarities which are of sufficient importance to warrant 
a special description of the features of what we may call a typical case. 
The observer of psychological phenomena does not require to be told 
that there are great, and even perplexing, differences in individual 
instances. In cases in which an attack on former occasions, hereditary 
tendency, or any other cause, may particularly direct our attention to 
the patient ; or when the observer has had much special experience in 
the treatment of insanity ; a certain restless, anxious manner, with more 
or less irritability, will sometimes presage the coming storm, and cer- 
tainly one of the worst possible of premonitory symptoms is obstinate 
insomnia, or unrefreshing rest broken by frightful dreams. We borrow 
from Dr. Ramsbotham the following graphic description of this, and the 
subsequent stages of the disease : — 

" In mania there is almost always, at the very commencement, a 
troubled, agitated, and hurried manner, a restless eye, an unnaturally 
anxious, suspicious, and unpleasing expression of face ; sometimes it is 
pallid, at others more flushed than usual, — an unaccustomed irritability 
of temper, and impatience of control or contradiction ; a vacillation of 
purpose, or loss of memory ; sometimes a rapid succession of contradic- 
tory orders are issued, or a paroxysm of excessive anger is excited about 
the merest trifle. Occasionally, one of the first indications will be a 
sullen obstinacy, or listlessness and stubborn silence. The patient lies 
on her back, and can by no means be persuaded to reply to the questions 
of her attendants, or she will repeat them, as an echo, until, all at once, 
without any apparent cause, she Avill break out into a torrent of language 
more or less incoherent, and her words will follow each other with sur- 
prising rapidity. These symptoms will sometimes show themselves 
rather suddenly, on the patient's awakening from a disturbed and un- 
refreshing sleep, or they may supervene more slowly when she has been 
harassed Avith watchfulness for three or four previous nights in succes- 
sion, or perhaps ever since her delivery. She will very likely then be- 
come impressed with the idea that some evil has befallen her husband or, 
what is still more usual, her child ; that it is dead or stolen ; and if it be 
brought to her, nothing can persuade her it is her own ; she supposes it 
to belong to somebody else ; or she will fancy that her husband is un- 
faithful to her bed, or that he and those about her have conspired to poison 
her. Those persons who are naturally the objects of her deepest and 
most devout affection, are regarded by her with jealousy, suspicion, and 
hatred. This is particularly remarkable with regard to her newly-born 
infant ; and I have known many instances where attempts have been 
made to destroy it, when it has been incautiously left within her power. 
Sometimes, though rarely, may be observed a great anxiety regarding 
the termination of her own case, or a firm conviction that she is speedily 
about to die. I have observed upon occasions a constant movement of 
the lips, while the mouth was shut ; or the patient is incessantly rubbing 
the inside of her lips with her fingers, or thrusting them far back into 
her mouth ; and if questions are asked, and particularly if she be 



6J:4 PUERPERAL INSANITY. 

desired to put out her tongue, she will often compress the lips 
forcibly together, as if with an obstinate determination of resistance. 
One peculiarity attending some cases of puerperal mania is the im- 
morality and obscenity of the expressions uttered ; they are often such, 
indeed, as to excite our astonishment, that women in a respectable station 
of society could ever have become acquainted with such language." 

We have no reliable information as to the number of cases which prove 
fatal, but there is no doubt that one of the most important symptoms as 
indicating the probability of a fatal result is extreme rapidity of the 
pulse. " Mania," said William Hunter, " is not an uncommon appear- 
ance in the course of the month, but of that species from which they 
generally recover ; when out of their senses, attended with fever-like 
paraphrenitis, they will in all probability die." Gooch corroborates 
generally this assertion, and narrates in illustration a very interesting 
case : '' One evening, several years ago, a surgeon called upon me, wish- 
ing me to return with him many miles into the country, to see his wife, 
who had become maniacal a few days after her delivery. I was at that 
time attending a lady in her first labor whom I could not leave, but I 
offered to go with him if he would wait till the labor was over. It was 
going on wearily, there was no prospect of its being over before the 
morning, and as he was anxious to return home, he took another phy- 
sician whom I recommended. Before leaving me, how^ever, he said he 
should like to talk with me about the case. I took down a volume of 
Dr. William Hunter's manuscript lectures, and showed him this passage 
(quoted above). He said he was sorry to read it, for that his wife's 
pulse was very rapid. About a week afterwards, I heard that she was 
dead." It would appear, however, as if the views of Hunter and Gooch 
had found too literal an interpretation in many modern treatises, for it 
would almost seem to be the deliberate opinion of some, that a rapid 
pulse meant death and a slow one recovery. The pulse is probably the 
most certain indication which we have ; but it is not to be relied upon 
solely, to the exclusion of others. Extreme rapidity in the beats is in 
this, as in all the other more serious disorders of the puerperal state, a 
symptom of grave import ; but too much has been made of it; and, for 
our part, we are quite convinced that there are many cases in which the 
pulse rises above 120, and remains at that rate for days in succession, 
and yet convalescence is ultimately quite satisfactory. When the pulse 
suddenly rises at the commencement of the attack, the symptom is un- 
doubtedly more alarming. 

In the worst cases, the milk and lochia are entirely suppressed ; but 
this is not usually the case, although both functions are more or less 
interfered with, the nutritive value of the milk, at least, being generally 
deteriorated. There is obstinate insomnia, which often defies the calm- 
in a; influence of the strongest drugs. The digestive functions become 
impaired in a marked degree, the tongue being furred, and the odor of 
the breath not unfrequently offensive. The urine is scanty and high 
colored, and the alvine evacuations are offensive — there being sometimes 
diarrhoea, but more frequently constipation. The cases in which the 
patient is extremely violent are exceptional; but it is often impossible, or 
at least a matter of great difficulty, to induce her to remain silent or at 



PROGNOSIS. 645 

rest. She insists on rising to discharge some imaginary neglected house- 
hold duty, and her delusions may turn into all kinds of odd channels. 
She in many instances refuses food, and it may, on this account, even be 
necessary to use force in order that such nutriment as is essential to 
maintain life may be introduced into the stomach. The delusion, in one 
very obstinate case of this nature which came under our observation, was, 
that putrefaction was going on internally, and that food only tended to 
supply material for the morbific process ; and in other cases it has been 
noticed, that, although the patient obstinately refused food when urged 
to take it, she would, if she could obtain it furtively, take it greedily and 
voraciously. Again, a prominent characteristic of these cases, which 
adds greatly to the responsibility of their management, is the undoubted 
tendency to suicide, which may show itself in many ways, although hid- 
den with all the craft and cunning of insanity. 

It has been remarked as a feature characteristic of puerperal mania, 
that, occasionally, the woman, although her mind is pervaded by delu- 
sions, has a strange underlying consciousness that her thoughts and ac- 
tions are under the influence of some mysterious power. It has been 
stated, that seldom or never is this consciousness of a delusion manifested 
in other forms of insanity. Gooch states that the symptoms, in some cases 
observed by him, closely resembled those of delirium tremens, and he 
has also seen symptoms, of the nature of catalepsy, which were asso- 
ciated with distinct puerperal mania. If we may accept as probable the 
theory to which allusion has already been made, — that albuminuria, in 
mania as well as in eclampsia, points to the proximate cause, — we cannot 
be astonished to find that clinical experience in some measure seems to 
indicate a connection between them. We even find, that by some the 
expression "epileptic puerperal mania" has been employed as indicating 
the occasional coincidence of the phenomena of eclampsia with those of 
mental aberration. In some instances the mania has been preceded by 
convulsions, Avhile in others the mental phenomena have been the first to 
develop themselves. 

The Prognosis of these cases involves, as will readily be understood, 
questions of deep interest in individual instances. As regards the risk 
to life, it is, as we have attempted to show, an error to suppose that a 
rapid pulse is necessarily the forerunner of death. But there is another 
error, which at one time led to a contrary belief. This finds expression 
in a remark which Dr. Gooch attributes to Dr. Baillie, who, when con- 
sulted about a case, remarked " that the question was not whether she 
was to get well, but when she was to get well." To this Gooch adds 
dryly, "the patient died a week after this prognosis." The fact is, that 
death from puerperal insanity does now and again occur, and more fre- 
quently from the maniacal than from the melancholic form. Dr. Churchill 
says that he should himself lay great stress, in forming a prognosis, upon 
the presence or absence of uterine complication ; and the observation, 
coming from such a source, merits careful attention. 

The question of prognosis involves not only the danger to life, but the 
prospect of speedy restoration to reason. In this respect, in so far as 
mania is concerned, we may look forward with considerable confidence, 
especially in the absence of hereditary predisposition, to an early re- 



646 PUERPERAL INSANITY. 

covery. "Within three weeks," says Dr. J. B. Tuke,^ "or more fre- 
quently earlier, the mania gradually subsides, and is replaced by a state 
of dementia, generally accompanied by delusions, which almost invari- 
ably assume the form of mistaken identity. These gradually disappear, 
leaving a haziness of apprehension, and a state suggesting the idea of 
waking from a dream. The patient can now, generally, be induced to 
work, and otherwise employ herself. From that moment you may look 
with almost certainty to ultimate recovery." There are cases, however 
— chiefly those of hereditary taint — in which the delusions become con- 
firmed, and in which, although the general health may have been quite 
restored, the mental aberration is persistent ; dementia, of a more serious 
nature than that mentioned by Tuke, gradually takes the place of mania, 
and hopeless chronic insanity is the result. 

Although in the insanity of pregnancy the majority of cases are of the 
melancholic type, it is otherwise with true puerperal insanity ; where 
melancholia, although by no means rare, is, as compared with mania, 
comparatively unfrequent. Few cases which, from the first, come under 
this category, present characteristic symptoms earlier than the sixteenth 
day, and a large proportion of cases come on considerably later than this. 
All at first may go on to our perfect satisfaction : the patient has been 
able to leave her bed at the usual time ; her appetite is good ; she sleeps 
well, and is able to nurse her child ; it is assumed on all hands that con- 
valescence has been satisfactorily established. Perhaps a month after 
the birth of the child, a change comes over the mother, which, to her at- 
tendants, is quite inexplicable. The pride and interest in a first-born 
child gradually fades away, and a cloud of sadness, utterly without cause, 
slowly spreads itself over the aspect and demeanor of the mother. Causes, 
which are either imaginary, or, if real, are of the most trivial character, 
give rise to fits of silent weeping, during which the patient is not demon- 
strative, and rather avoids than seeks sympathy. The gloom deepens as 
the curtain falls. No longer does the cry of the infant awaken a tender 
sympathy in her heart ; on the contrary, she maintains a moody silence, 
and not only never inquires for her infant, but seems to look upon it with 
actual aversion. Delusions — all of the melancholic type — if they have 
not already manifested themselves, now become apparent. She believes 
that in marrying she has violated some important moral obligation. While 
she heaps all sorts of accusations on her own head, she comparatively rarely 
complains of others. Too frequently the religious element enters into her 
morbid ponderings, and she fancies herself lost, and her soul beyond all 
hope of salvation. 

And not by day only, but by night, do these gloomy impressions 
weigh upon her mind, so that sleeplessness is an early and most 
troublesome symptom, resisting often all the ordinary methods of allevia- 
tion. The appetite fails, or becomes capricious ; or she may absolutely 
refuse to take any nourishment, except upon earnest solicitation, or even 
the employment of force. As the lochial discharge has most likely 
ceased before the symptoms of insanity make their appearance, no refer- 
ence need be made to that; but, as regards the lacteal secretion, it will 

J Edinburgh Medical Journal, May, 1865. 



TREATMENT. 647 

generally be observed that, even in robust women, who previously had 
an abundance of milk, it is rapidly arrested, and the breasts become 
flaccid. The bowels are sometimes tolerably regular, but, as a rule, are 
constipated, and the dejections fetid. The urine is high in color and 
scanty, unless there is an hysterical element in the case, when there may 
be a great flow of a low specific gravity. The pulse may be accelerated, 
but is seldom so continuously. In some instances, symptoms of moral 
insanity are prominent. In cases in which there has been — even long 
previously — a tendency to intemperate habits, these may re-appear, in 
the earlier stage, in the form of aggravated dipsomania, in which the 
morbid craving for stimulants may assert itself in the most intense form ; 
and the patient will, if unable to procure ordinary stimulants, greedily 
consume eau-de-Cologne, spirits of sal volatile, tincture of valerian, or 
spirits of lav^ender, should such be left within her reach. And, in like 
manner, the pica of pregnancy may appear in an exaggerated form, when 
she will eat soap, or even more disgusting substances which may be at 
her command. 

The progress and ultimate issue of such a case are matters which give 
cause for deep apprehension. It is not a fatal result that we dread so 
much as permanent insanity. The observation of Gooch on this point 
merits the dignity of an aphorism, when he says that " mania is more 
dangerous to life, melancholia to reason." When the two varieties — 
mania and melancholia — are considered together, it has been said that 
the period of convalescence ranges from a few days to two years ; but, 
if we take the trouble to analyze the cases, and separate the one class 
from the other, it will become quite obvious that the examples of pro- 
tracted convalescence are, almost invariably, those in which melancholy 
has been the prevailing type. And, in like manner, if we avail ourselves 
of such statistical observations as may seem most reliable, it is equally 
clear that the melancholic cases attbrd by far the greater number of 
those instances in which reason has permanently succumbed. In so far 
as Ave can gather from the observations of those who have given most 
attention to the subject, it would seem that the existence of albumen in 
the urine has no such marked association with puerperal melancholia as 
it has with mania of the same class ; but this is a point in regard to which 
more extended clinical study is still required. 

Treatment. — From every aspect of the case, the treatment of puerperal 
insanity is a subject of surpassing clinical interest, and one which de- 
serves, we venture to assume, more attention than has, in some system- 
atic works, been accorded to it. This is particularly the case as regards 
prevention ; for we can scarcely doubt that, when the symptoms are such 
as to indicate disturbance of the cerebral functions, much may be done, 
in the way of warding ofi" an attack, by a judicious employment of the 
remedies to be hereafter mentioned. This remark applies chiefly to 
cases where there is a marked hereditary taint, or where the patient has 
been insane at previous confinements. An illustration of the latter came 
recently under the notice of the writer. 

A delicate lady, who had married very young, became maniacal about 
ten days after her first, and again nine days after her second confinement, 
and on the latter occasion the convalescence had been extremely pro- 



648 PUERPERAL INSANITY. 

tracted, and the danger to life at one time great. Much anxiety was 
naturally felt by herself and her friends on the approach of a third con- 
finement, particularly as, towards the end of the ninth month, she became 
hysterical, sleepless, and melancholy, as on the former occasions. A 
very remarkable feature in the case was the tendency to dreams of a 
disturbing kind, Avhich not only rendered such sleep as she obtained un- 
refreshing, but made her actually dread falling asleep. The state of the 
tongue and dejections indicated considerable derangement of the digestive 
functions. As the period of expected delivery approached, the symptoms 
became still more marked ; but they seemed to be, in some degree, under 
the control of the remedies which were adopted, — the most effectual being 
chloral hydrate for the nervous symptoms, and colocynth with hyoscyamus 
for the bowels. Labor passed over quite favorably and in every respect 
satisfactorily, the patient being, however, as might have been anticipated, 
very feeble and exhausted after its completion. After delivery, very 
strict precautions were observed to maintain perfect quietness, and free- 
dom from any possible worry or annoyance. A certain amount of sleep 
w^as obtained by chloral: opium made matters w^orse. The child was not 
put to the breast, and the lacteal secretion was easily kept under. It 
was, in this case, a matter of intense interest to watch the struggle for 
reason; for, although at no time did she exhibit S3^mptoms of insanity, 
there was not the slightest doubt that she was on the verge of it; but, 
happily, after a fortnight had elapsed, she rapidly improved, her appe- 
tite increased, and she enjoyed natural and refreshing sleep ; until ere 
many more days had passed, she was pronounced convalescent. It is 
too much to assume that this narrative proves that an impending attack 
of mania was warded off; but the impression is, nevertheless, fixed on 
the minds of those who watched the case, that constant and anxious 
supervision, and, above all, skilful and judicious nursing, saved the 
patient from a recurrence of her malady. 

The cases, however, in which preventive treatment can be expected to 
be of much avail, are probably of very rare occurrence ; and there, no 
doubt, is a danger — against wliich we would caution the inexperienced — 
of looking with apprehension upon what our fears may magnify into pre- 
monitory symptoms, and thus adopting, on insufficient grounds, methods 
of treatment, upon the successful results of which we complacently con- 
gratulate ourselves. 

The symptoms which accompany a violent attack of puerperal mania, — 
when there is rapid pulse, heat of head, and great cerebral disturbance, — 
are such as very readily to explain how, for so long a period, the lancet 
was employed as a measure of the veriest routine. Apart from the 
theory of phrenitis, the very violence of the symptoms seemed to demand 
prompt and free blood-letting. The change which public and professional 
opinion has undergone during the last forty years is, however, such that 
we scarcely think it necessary to recommend caution in regard to this 
once familiar remedial measure. Were it otherwise, we might point to 
many facts which conclusively prove that puerperal mania is essentially 
a disease of debility; and that, if the heat of head and other local 
symptoms should seem to suggest the application of leeches to the tem- 
ples, even this practice must be adopted with the greatest possible caution; 



NERVOUS SEDATIVES. 649 

for cases have undoubtedly occurred, in Avhich a very moderate loss of 
blood has precipitated a fatal result. In cases of actual meningitis, blood- 
letting is, of course, in some form or other, urgently demanded; but no 
real difficulty should prevent the discrimination of these very rare cases 
from the ordinary varieties of puerperal mania. 

The gastro-intestinal disturbance, which is so invariable an accompani- 
ment of the case, requires, from the first, careful attention, and generally 
prompt treatment. If the bowels, therefore, are overloaded, a purgative 
should at once be administered ; and although we must not expect an 
immediate cure, as in one of Gooch's cases, we may look for some relief 
in the symptoms, and especially of the irritability and restlessness so 
characteristic of the disease. But it will not suffice simply to see that 
the bowels are thoroughly cleared of their contents, which are often 
highly offensive ; for, be the case long or short in its duration, the judi- 
cious regulation of the bowels is one of the most important indications of 
treatment. For this purpose, aloetic purgatives are appropriate, from 
their derivative action. It would appear that, in some cases, signal 
benefit has been derived from the admmistration of emetics. " If the 
powers of the constitution are not low, and the gastric symptoms are very 
marked, — namely, a foul tongue, an oftensive breath, and a yellow eye, — 
an emetic, not of antimony, but ipecacuanha, may be given." So wrote 
Gooch, and most modern writers have repeated his recommendation of 
emetics, at least as an exceptional method of treatment. Care must be 
taken, of course, not to administer those depressing agents when the face 
is pale, the skin cold, and the pulse quick and weak ; and, indeed, the 
more prominently we keep before us the leading fact, that puerperal in- 
sanity is a disease of debility, the less likely will we be to have recourse 
to antiphlogistic remedies. 

Although blood-letting is, for reasons already fully explained, contra- 
indicated, there is often observable such a degree of vascular excite- 
ment, that we may naturally inquire whether this cannot be allayed by 
some safer measures. The application of cold to the head, or, what is 
even better, laving the forehead and temples Avith w^arm water — after 
which there is a refreshing feeling of coolness — may produce the desired 
eflect. In other cases, we may administer any of the vascular sedatives, 
of which none, probably, will be more likely to effect the purpose we 
require than tartar emetic, in such doses as may be necessary to produce 
a depressing effect — taking great care, for obvious reasons, not to push 
it too far. One or two drops of the tincture of aconite, or of the tinc- 
ture of veratrum viride, have been recommended by Simpson for the same 
purpose. 

Undoubtedly, the most important remedies to which we have to refer 
are the class of nervous sedatives. At the head of the list stands opium 
— the sheet-anchor, as it has been called, of the alienist physician. It 
is to be observed, however, that there exists a considerable diversity of 
opinion as to the propriety of administering opium in the puerperal 
varieties of insanity. It is quite certain that in some cases it proves of 
no avail, while in others the result is the reverse of beneficial. Simpson, 
Avho admits this, says, " Whatever may be the Avay in which 3^ou give 
the drug, remember always, as the general rule to guide you in its 



650 PUEKPERAL INSANITY. 

administration to snch patients, that it must be given in very large doses. 
If you expect to have any good effect from it, you must give, in general, 
not less than two or three grains of solid opium, or an equivalent dose of 
some of the cognate preparations." If unusual difficulty is encountered 
in the administration of the drug in the ordinary way by the mouth, the 
same autliority recommends the introduction into the rectum of a sup- 
pository containing one or two grains of morphia ; and he mentions an 
interesting case in which that was followed by a sleep of sixteen hours, 
from which the patient awakened quite free of maniacal symptoms. Dr. 
Tuke observes that the exhibition of opium, as well as of the other nar- 
cotics, is not beneficial when the leading symptom is acute mania ; and 
it is well that we should bear this observation in mind as coming from 
one of much experience in the treatment of all forms of insanity. In 
some instances, chloroform has been employed with much benefit, the 
patient being brought fully under the eifect of the anaesthetic, a little 
more being given from time to time as she seems about to wake. Hyoscy- 
amus, in combination with ether or ammonia, and Indian hemp, have also 
been employed with the same object. Camphor was Gooch's favorite 
remedy, but it is not now so frequently employed as at one time it was. 
Chloral hydrate is another remedy which has of late, to some extent, 
superseded opium in the treatment of insanity, as in many other dis- 
orders ; and experience seems to show, that in this drug we have a most 
important addition to the materia medica of the class of diseases in 
question. The use of the warm bath should not be forgotten in an 
enumeration of sedative agents, and there can be no doubt, that by 
it a beneficial effect is produced even when drugs have failed. Let us 
always remember that the primary object which we have in view, in the 
exhibition of this class of remedies, is to procure sleep. If we succeed 
in our object, the patient may at once recover ; but, unfortunately, as a 
rule, she relapses, on awaking, into the violence and delusions of her un- 
happy state. 

As regards diet, unless deterred by special circumstances, such as 
gastric or intestinal derangement, we should at once permit the use of 
soups in moderation, along with other substances of easy digestion which 
may suggest themselves. In many cases, a small quantity of wine may 
be added, to be increased as the necessities of the case may seem to 
require. As the case goes on, it will generally be proper to give more 
generous diet, and to be more liberal, it may be, in the use of stimulants ; 
for we may be perfectly sure that, as this was a disease of debility from 
the first, an improved physical condition is an essential concomitant of 
recovery. 

The general management and control of the patient involves the im- 
portant points of seclusion and restraint. Our aim, in this respect is, 
above all, to guard the woman from whatever may prove a source of ex- 
citement. The experience of every one clearly proves, that to permit 
of free association with relatives and friends is, in the highest degree, 
injudicious. Such interviews give rise to excited appeals as to being re- 
lieved from the irksomeness of restraint, and generally awaken in the 
mind painful impressions, which leave the patient for a time in a worse 
mental condition than before. In most cases, therefore, in which the 



TREATMENT OF MELANCHOLIA. 651 

symptoms show unusual obstinacy, it is well to separate the patient from 
her friends, and to leave her entirely to the management of those who 
have special experience in the treatment of the insane. This should, if 
possible, be done in her own house, for we confess to a great reluctance 
to send persons suffering under this comparatively curable variety of 
insanity to be immured in a lunatic asylum, to associate, probably, with 
persons whose minds are permanently deranged. We do not deny the 
advantage of a system of constant and intelligent supervision, but if this 
can be equally well secured at home, it is always well to avoid the 
stigma which attaches to confinement in an asylum, and which many 
women, after their recovery, will feel most, acutely. As reason is 
gradually being restored, too great caution can scarcely be exercised in 
permitting her to renew her intercourse with her friends ; and, if it 
should seem that interviews with them still excite her, the period of 
seclusion must be extended. There are cases, however, in which the 
visit of a relative or friend has the best possible effect, in diverting the 
mind from its morbid condition into channels which are more healthy, by 
reason of the association of ideas which recall the past. It is at this stage 
that change of air and scene is more particularly beneficial. During the 
whole course of treatment, the patient should not be left for a moment 
alone, and as a prominent characteristic in such cases is suicidal impulse, 
it is always proper to see that nothing be left within her reach which 
might render self-injury possible. 

The treatment of melancholia differs in some respects from what has 
been prescribed as proper to the maniacal variety. There will, for 
example, in cases which manifest this type of insanity, be no necessity 
for the use of any of the vascular sedatives, as the circulation is little, 
if at all disturbed. From the first, therefore, we should adopt a more 
nutritious regimen than in the other and more frequent cases ; but, 
unfortunately, we must look forward to a long illness and lingering 
convalescence, and, in some unhappy instances, to the symptoms grad- 
ually being merged in those of hopeless dementia. It will more fre- 
quently be found necessary, in the melancholic cases, to remove the 
patient from home, and even to place her in strict confinement. 

The question of the recurrent nature of the disease is the only other 
point upon which we need touch ; and it is one in regard to which 
authors do not seem to be agreed. Gooch thinks that it is unusual ; 
but a careful observation of such meagre statistical facts as are at our 
command seems to point strongly to the conclusion that there is a 
decided tendency to the recurrence of the disease in the subsequent 
pregnancies of women who have previously been the subjects of puer- 
peral insanity. It is m cases in which there is an hereditary taint that 
this is most distinct, but the tendency in all cases is sufficiently marked 
to warrant us in taking every precaution to avoid the other exciting or 
predisposing causes of the disease. Tuke's cases were recurrent in the 
proportion of fifteen out of seventy-five. 



652 PUERPERAL ECLAMPSIA, 



CHAPTEE XLII. 

PUERPERAL ECLAMPSIA. 

Defnition. — Connection between Eclampsia and Acute Bright' s Disease. — Eclamp- 
sia from other Morbid Conditions. — Effects of Pregnancy on the System. — 
Period of Explosion. — Symptoms: Premonitory Signs ; (Edema., Albuminuria., 
Cephalalgia^ ^c. — Phenomena of the Fit : Period of Tonic and Clonic Gon- 
vidsions, and of Coma. — Pathology : Albuminuria : Decomposition of Urea, 
and Formation in the Blood of Carbonate of Ammonia : Effects of Pressure 
on the Rencd Veins : Detection of Albumen in the Urine. — Morbid Anatomy. 
— Effect of Labor Pains. — Maternal and Foetal Mortality. — Prognosis: in 
Eclampsia Gravidarum., Parturentium., et Puerperarum. — Treatment: Pro- 
phylaxis : Use of Acids: Purgatives and Diuretics : Induction of Premature 
Labor: Treatment during the Fit : Blood-letting: Chloroform: Chloral: Ob- 
stetrical Treatment at Various Stages of Labor : Acceleration: Rupture of the 
Membranes : Use of the Forceps. 

Under the designation of Puerperal Eclampsia are included, not only 
such instances of the malady in question as are manifested during the 
puerperal period, but all cases, without exception, which are observed 
in the course of pregnancy, during labor, or after delivery. It was for 
this reason that we deferred any notice of Eclampsia as a complication 
of gestation or delivery, until, having the whole subject before us in its 
broadest aspect, we should be in a position to review the highly interest- 
ing speculations to which modern pathology has of late so largely con- 
tributed. 

It is scarcely necessary to remark that the affection which -we are 
now about to consider does not include all cases, without exception, in 
which symptoms of the convulsive or epileptiform type manifest them- 
selves during pregnancy or child-bed. It is, for example, a disorder 
distinct from, although, in its more conspicuous phenomena, closely 
analogous to epilepsy. But, so great is the preponderance of cases in 
which the symptoms of true puerperal eclampsia exist, that we think 
we are perfectly justified in agreeing with those who look upon a certain 
train of symptoms and pathological facts as essential, or nearly so, to 
the disease in question. " Eclampsia puerperalis," says Braun, "is an 
acute affection of the motor function of the nervous system, charac- 
terized by loss of consciousness and of sensibility, by tonic and clonic 
spasms, and occurs only as an accessory phenomenon of another disease, 
generally of Bright's disease in an acute form, which, under certain 
circumstances, spreading its toxseraic effects on the nutrition of the 
brain and the whole nervous system, produces those fearful accidents. 
The toxa3mia (or blood-poisoning) in eclampsia gravidarum, parturen- 



VARIETIES OF ECLAMPSIA. G53 

tium, et puerperarum, is commonly produced by ur?emia ; i.e.^ by a 
change of urea which is retained in the blood, or by retention of the 
excrementitious constituents of the urine. . . . Under the com- 
mon appellation of ' Eclampsia' several pathological processes have 
hitherto been comprehended, which do not even present an identical 
series of symptoms, and which have only this in common, that there 
exist tonic, and specially clonic spasms, along with loss of sensibility." 

The exceptional varieties of eclampsia, to which the author here refers, 
are cases in which the origin is to be discovered in defective purification 
of the blood, arising from quite dift'erent causes, — such as imperfect 
elimination of carbonic acid through the lungs, the retention of bile in the 
blood (^cJioIcemia) ^ or the operation within that fluid of certain other 
septic agents, — the nature of which is little understood, — such as are 
developed occasionally in the course of typhus, or some other continued 
fever. Epilepsy, when it occurs, is to be distinguished partly by the 
symj)toms of the attack, but more particularly by the absence of albu- 
men in the urine, both before and after the attack. Cases have been met 
with, in which the cause was presumed to reside in an altered condition 
of the blood, as regards the proportion of its various normal ingredients, — 
such as hyperinosis, lukgemia, or hydrgemia. One of the symptoms which 
immediately precede dissolution, in cases of hemorrhage, is a convulsive 
seizure, presenting most of the features of eclampsia, and supposed by 
most authorities to be due to anaemia. Finally, and putting aside the 
cases in Avhich convulsions are due to some diseased condition or func- 
tional disturbance of the nervous centres, there are other instances, in 
which an irritation of the peripheral nerves gives rise, by a reflex action, 
to similar symptoms, which are often associated with other hysterical 
manifestations, and are therefore called, with some propriety, hysterical 
convulsions. With rare exceptions, then, arising from these or similar 
causes, puerperal eclampsia may be looked upon as essentially connected 
with urt^mic poisoning, which again, is associated with, or dependent upon, 
an albuminous condition of the urine. 

Before entering upon the consideration of the symptoms and pathology 
of this alarming disorder, it may be well to look closely, were it but for 
a moment, upon some of the conditions essential to the pregnant state. 
The constitutional sensitiveness, to which we have already more than once 
referred as eminently characteristic of pregnancy, can scarcely fail to 
display itself in its relation to the nervous system and its all-pervading 
influence. Dr. Barnes argues' with much ingenuity, in favor of a theory 
which he advances, that nature provides, against the period of parturi- 
tion, a special supply of nerve-force ; that this is associated with an in- 
creased irritability of the nervous centres ; and that it implies a corres- 
ponding organic development of the spinal cord. This involves, we ap- 
prehend, pretty much the same idea as that which we have expressed, 
although it is couched in more precise and more philosophic terms. What 
more likely, may we not infer, than that the force of the nervous system 
thus surcharged may, by derangement of excited signals, be reflected 

' See liis Lumleian Lectures on the Convulsive Diseases of Women. Lancet. April. 
1873. 



654 PUERPERAL ECLAMPSIA. 

upon the wrong track, and thus cause convulsive action in unlooked-for 
quarters, and frequently disaster as the result ? But, besides this, we 
cannot but regard the altered condition of the blood in pregnant women, 
as, in some degree, predisposing to a morbid condition, one of the essen- 
tial factors of which is an abnormal state of the blood itself. These 
changes, as formerly mentioned, consist in an increase of water and of 
fibrine, a diminution in the quantity of albumen, and a reduction in the 
proportion of the red, with a relative increase in the white corpuscles. 

There is another point of great interest, to which Barnes directs atten- 
tion in his lectures above alluded to, — that all generative acts manifest 
an emotional and a convulsive element. '' It further deserves to be noted 
here, that emotion takes a large part in every act or process of the gene- 
rative function. In short, emotional affectability is the measure of con- 
vulsive liability. Another proposition I would state is the correlative of 
the preceding one. It may not be quite so obvious in its truth, but I think 
I shall be able to show that it is equally constant. It is this : — An energy 
which may be compared with, if not identical in nature with, convulsion, 
is an essential element in the leading acts of the generative function. I 
have known instances of an epileptic fit being repeatedly induced by the 
sexual act. I have heard of several other like cases. Voisin mentions 
one. La Motte knew a woman who, not pregnant, always vomited sold 
aetione coitus. ^^ 

The period at which eclampsia most frequently develops itself is gene- 
rally stated to be during the course of labor. As, however, it is also 
noticed for the first time during the last weeks of pregnancy in a large 
number of cases, and as labor is often an immediate result of a convul- 
sive seizure, it cannot be an easy matter to determine what is its relative 
frequency with regard to the three periods of pregnancy, labor, and 
childbed. According to Braun and Wieger, more than half of all cases 
occur during labor, but, for the reason above stated, this may well be 
admitted as doubtful ; and, for our part, we are inclined to agree with 
the conclusions of the writer of the able article on this subject in the 
Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques^ that the 
relative frequency of the three epochs is correctly expressed in the fol- 
lowing order, — pregnancy, — labor^ — after delivery. Statistics are not 
much to be relied upon, but it may be noticed that an average of English 
and Continental practice seems to yield about 1 case of eclampsia in 350 
labors. 

Symptoms. — Although the convulsive seizure sometimes comes on 
quite unexpectedly, there are probably few cases in which premonitory 
symptoms of some kind or other might not have been detected. One of 
the most important of the premonitory symptoms is oedema, which, indeed, 
is of common occurrence, especially in the ankles, feet, and labia majora. 
The oedema is generally developed some weeks before the appearance of 
the first fit, and it is occasionally, although somewhat rarely, to be ob- 
served in the upper part of the body and in the face. Should this 
symptom be manifest, the suspicion of the attendant will, almost as a 
matter of course, be excited, with the result of an immediate examination 
of the urine, which may be found to yield a large quantity of albumen 
by the ordinary test of heat and nitric acid. The microscope, in most of 



SYMPTOMS. 655 

these cases, reveals the presence in the fluid of hyaline tube casts, with 
or without blood corpuscles; or it may indicate, by appearances familiar 
to the pathologist, the presence of more advanced and serious renal dis- 
order. 

In a considerable number of instances, no oedematous indication at- 
tracts attention, even although undoubted albuminuria exists ; but, when 
this more conspicuous and familiar symptom is absent, there are other 
premonitory symptoms, which in some cases are of high importance, ami, 
in all, demand careful attention. According to Chaussier, there are 
three symptoms which, as premonitory indications, deserve special at':en- 
tion : these are cephalalgia, derangements of vision, and epigastric pain. 
The headache — which is the most frequent of all — is extremely acute, 
and is usually complained of in the frontal region. At first it is inter- 
mittent, but subsequently, and especially when the fit is near at hand, 
the plan often becomes continuous. When the sense of sight is in any 
way disturbed, this is justly looked upon as an indication of grave im- 
port. There is, at first, either cloudiness or dimness of vision, or that 
peculiar indistinctness which gives one the idea of looking through the 
highly rarefied atmosphere over a furnace — familiar to those who are 
the subjects of trifling biliary derangements. In other examples, objects 
seem to exhibit peculiar colors, and the vision becomes gradually more 
impaired, although in some instances the affection is intermittent. Very 
often the loss of sight does not come on till immediately before the fit, 
and cases have probably been witnessed by most practitioners of expe- 
rience, in which a patient, either during labor or before it, complains of 
sudden and complete loss of vision, and in a few minutes, or it may be 
seconds, is overwhelmed with the most violent eclamptic seizure. The 
third of the premonitory symptoms of Chaussier, epigastric pain, is of 
less frequent occurrence than the other two. The suft'ering is described 
as being extremely severe, lasting often for hours ; and when it is of 
unusual severity, it is said to be an almost certain precursor of a convul- 
sive attack. In a considerable proportion of all cases of the affection, 
no albumen is to be detected, and this is a fact which must be carefully 
borne in mind. 

The convulsive seizure characteristic of true puerperal eclampsia varies 
so little, save in intensity and duration, that to have witnessed and care- 
fully observed even a single attack will suffice to make one familiar with 
its main diagnostic features. The following description of the fit is in a 
great measure borrowed from the essay already alluded to: — Probably, 
after some of the precursory symptoms already described, the patient 
seems deeply absorbed and pre-occupied ; then her gaze becomes fixed 
for a few seconds, and the fit commences immediately by rapid contrac- 
tions of the muscles of the face, of the eyelids, and of the eyeballs, which 
seem to roll in their sockets. These twitching movements, which give to 
the countenance a most painful expression, presently give place to tonic 
contractions of the same muscles, and of the neck. The mouth is first 
twisted towards the left, and the face is slowly turned towards the 
shoulder of the same side. The up-turned eyeballs show, through the 
half closed eyelids, the inferior segment of the sclerotic. After being 
slowly turned to the left, the face, by a movement in the contrary direc- 



656 PUERPERAL ECLAMPSIA. 

tion, turns towards the right shoulder. From the head, the convulsive 
phenomena rapidly extend to the other parts of the body. The extensors 
of the trunk, thrown into violent contraction, tend to bend the spinal 
column backAvards (^opisthotonos). The trunk becomes perfectly rigid. 
The legs are equally so and generally extended. The hands close with 
force, the thumbs being bent inwards upon the palm, and grasped by the 
other fingers. Occasionally, the predominant action of the flexor muscles 
has the effect of fixing the different segments of the superior extremities 
in a semi-flexed position, so that the arm sometimes takes the attitude 
which is given to it to protect the head from a menaced blow. Finally, 
the diaphragm and the respiratory muscles become involved. Respira- 
tion is suspended; the face becomes livid ; and the tongue, if projecting 
from the mouth at the commencement of the fit, is seized and lacerated 
by the spasmodic closure of the jaws, and the blood, which escapes from 
the wound thus produced, tinges the saliva which flows from the lips. 
The muscles of the larynx, and possibly those of the throat, being 
strongly convulsed, close these orifices. Consequently, the air, com- 
pressed by the convulsive constriction of the thorax, can only escape with 
great difficulty, and produces a peculiar interrufjted hissing expiration. 
There is observed, at the same time, a complete loss of consciousness and 
of all sensation. The patient neither sees nor hears ; and if we pinch or 
burn the skin, she makes no attempt to withdraw from an irritation of 
which she does not seem to have the slightest perception. 

Clonic convulsions, affecting the whole muscular system, soon succeed 
the tonic variety. Jerking movements of the head, trunk, and limbs, 
take the place of the general rigidity of the preceding period. Fright- 
ful contortions of the countenance are the result of irregular movements 
of the mouth, eyelids, and eyeballs. While respiration is being re- 
established in the interrupted fashion above alluded to, a frothy, and 
often bloody foam is forced from between the lips. The movements of 
the trunk and limbs consist of twitchings, so trilling in extent as merely 
to move the body without displacing it, so that there is not the same 
necessity for restraint as in some other convulsive diseases. The pulse, 
if strong and full at the commencement of the fit, is rapidly accelerated 
under the influence of the muscular and respiratory disturbance, and be- 
comes extremely feeble towards the height of the paroxysm. It some- 
times happens that the contents of the bladder and rectum are voided 
during the attack. 

As the fit passes off, all these symptoms progressively decline. The 
balance of the respiratory and circulatory functions is restored ; the 
color of the surface becomes natural ; the movements of trunk and limbs 
become feebler and less frequent, and finally cease. In a word, the 
convulsive manifestations of eclampsia may be divided into two distinct 
periods. The first, which is characterized by tonic convulsions, seldom 
lasts more than twenty or thirty seconds ; the second period, that of 
clonic convulsions, lasts much longer — from one to five minutes, or even 
more. The gradual restoration of the respiratory function during this 
second period, prevents any special danger to life ; and it is, therefore, 
during the first, or tonic period only, that there is immediate risk. After 
the fit has entirely ceased, the patient remains in a comatose condition, 



PATHOLOGY. 657 

the depth and duration of which is in proportion to the intensity of the 
paroxysm, so that the patient may regain consciousness in a few minutes, 
or after the lapse of many hours. A dull languor, or a confused feeling, 
with headache, is then very generally complained of, and it may thus be 
some time before the patient completely recovers. This is, of course, 
supposing that she has but one attack, or that a considerable interval 
occurs between them. In extreme cases, the tonic phenomena are such 
in intensity and duration that the patient's life is at once sacrificed ; 
and, in those cases in which the fits succeed each other with great 
rapidity, the patient has, as it were, no time to regain her consciousness, 
and she remains in a condition of complete coma, which is onl}^ disturbed 
by the recurrence of the dreaded paroxysms, and which persists until the 
case terminates either in recovery or death. 

Pathology. — In considering the morbid conditions, and the laws which 
regulate the abnormal muscular action of puerperal eclampsia, we shall 
confine our observations almost exclusively to the true or urasmic variety, 
so admirably described by Braun. We have already admitted that 
cholgemia, and the many varieties of toxaemia, may give rise to symptoms 
which are apparently identical with those of uraemic eclampsia. In like 
manner, epileptic patients may, during labor, or at any subsequent stage, 
be attacked with convulsive seizures, which the previous history of the 
case, the occurrence of the " aura," and the absence of albuminuria, will 
usually enable us to discriminate. Hysteria, too, may simulate many of 
the symptoms which have been detailed, but in this case also, the absence 
of albumen — with a history of " globus," " clavus," or abundant urine, 
and an imperfect insensibility during the fits — should prevent us from 
falling into serious error. But to enter upon the comparative pathology 
of all these afi'ections would lead us far beyond bounds, and we must 
therefore content ourselves, by stating, as concisely as possible, what 
has been established or conjectured in regard to the ordinary or uri-emic 
variety. 

That albuminuria and puerperal eclampsia are mutually dependent 
upon each other, or, at least, are of simultaneous occurrence in the vast 
majority of all cases, is an assertion not likely, in these days, to be 
seriously controverted. But it is by no means agreed, as to the albu- 
men and the paroxysm, which is the cause and which the effect. Accord- 
ing to Braun, and those who support his views, the albumen appears in 
the urine as the result of that inflammatory afiection of the kidney com- 
monly known as Bright' s disease. As a result of this, the blood is 
poisoned with excrement! tial elements of the urine, and especially with 
urea. The experiments and researches of Frerichs, alluded to in the 
previous chapter, have conclusively shown that the presence of urea in 
the blood, even in considerable quantity, does not give rise to eclampsia ; 
and the conclusion which he has reached is, that the active poison is the 
carbonate of ammonia, produced, as he assumes, by the decomposition of 
the urea, which must, therefore, be acted upon by some particular fer- 
ment, the nature of which has yet to be discovered by the pathological 
chemist. Frerichs does not admit the essentially inflammatory nature of 
the disease ; at least he appears to do so only to a limited extent, when 
he assumes, in explanation of the formation of the hyaline tube-casts, 



658 PUERPERAL ECLAMPSIA. 

that the inflammatory theory can only hold good in so far as the exuda- 
tion of blood-plasma is connected with a paralytic dilatation of the capil- 
laries. Braun, however, broadly maintains that the disease is of inflam- 
matory origin, and that the nature of the morbid process is identical 
with that of Bright' s disease. 

The other theory to wdiich we have referred is that held by those who, 
while admitting the existence of albumen in the urine, as an essential 
phenomenon, assert that this is the effect of eclampsia, and not its cause 
— which is, by them, supposed to be the result of some blood disease, or 
of some blood poison, hitherto unknown to science. And certainly the 
fact that, in so many instances, the convulsions precede the albuminuria, 
lends some confirmation to this view. 

We think that Braun is too absolute in his assertion that Bright's 
disease is the cause of puerperal eclampsia. He does not, indeed, deny 
the existence of the anaemic and other varieties already named, but he 
gives the latter so little prominence that one is apt to conclude from 
his description, — what, probably, he never intended, — that their im- 
portance is so little that they scarcely micrit notice. No one, obviously, 
can take a clear and comprehensive view of the pathology of puerperal 
eclampsia, who does not freely admit that there are cases in which no 
urgemic poisoning exists. There is, however, we think, no impropriety 
in the present state of our knowledge, in employing the term " true" 
as synonymous with " ursemic," in the nomenclature of puerperal 
eclampsia. But there is another point, in regard to which Braun 
seems to have carried his theory too far, or, at least, in regard to which 
he has failed to prove his case, — viz., that all cases of albuminuria are 
necessarily examples of true Bright's disease. Frerichs's idea on this 
point seems much more likely to be correct, for, if we do not misunder- 
stand him, he appears to say that, although fibrinous exudation and 
albuminous urine indicate, undoubtedly, the first stage of Bright's dis- 
ease, and in that case have an inflammatory origin, it by no means fol- 
lows that the same symptoms cannot, by any possibility, proceed from 
other than inflammatory causes. 

When the uraemic theory was advanced, it was assumed as possible 
that, in a large proportion of cases, albuminuria and the consequent 
succession of pathological changes were due to pressure on the renal 
veins. This has been, to a certain extent, experimentally proved ; and, 
indeed, it seems to afford the only satisfactory explanation of the rapid 
disappearance of all symptoms of renal disturbance upon the delivery 
of the woman ; an issue which we could not look for with equal confi- 
dence in any other case, unconnected with pregnancy, in which an 
examination of the urine gave the same chemical and microscopical 
results. We do not for a moment mean it to be inferred that pressure 
on the renal veins can account for all cases. On the contrary, it is well 
known that the symptoms may, although very exceptionally, be de- 
veloped, either early in the pregnancy, or after delivery, when such 
pressure as is implied is obviously impossible. But we do think that 
the subsequent history of cases of puerperal eclampsia affords some 
ground for the supposition that the theory is worthy of more attention 
than Braun and Lever seem to have accorded to it. If, on the other 



MORBID ANATOMY. 659 

hand, the dissections of Frankenhauser are to be held as demonstrating 
a direct connection with the nerves of the uterus, we must admit it as 
possible — as was indeed long before conjectured by Tyler Smith — that 
the nervous system and not the vascular system may after all be the 
starting point of puerperal eclampsia. 

The presence of albumen in the urine is shown very clearly by the 
ordinary tests, of which the cold nitric acid test is one of the most 
delicate. By this method, a small portion of urine is placed in a test 
tube, which, being held at an angle, while strong acid is sloAvly poured 
down the side, allows the acid to flow to the bottom. If albumen be 
present, and the experiment carefully performed, the contents of the 
tube then show three zones, — the upper, clear urine ; the lower, clear 
acid; and the intermediate zone, where the two fluids have mingled, 
an opaque layer of coagulated albumen. It is unnecessary to detail the 
various fallacies which are to be guarded against in testing for albumen, 
as these are now familiar to every clinical student. The observer 
should not forget that albumen is sometimes ■ present intermittently, 
and that, therefore, a negative result by the tests is not conclusive 
evidence of a satisfactory discharge of the renal functions. The cylin- 
drical tube-casts are most easily distinguished, according to Braun, if 
we examine the fresh urine, about an hour after it has been drawn off 
by the catheter, withdrawing, by means of a pipette, a few drops of the 
fluid from the bottom of the vessel. These casts, however, it should be 
remembered, may be absent in alkaline urine, as they are dissolved in 
the carbonate of ammonia, which is the product of decomposition of the 
urea. Very elaborate descriptions are given by Frerichs of the different 
varieties of tube-casts, but such observations belong more strictly to the 
pathology of a renal disease than to the explanation of a puerperal 
disorder. We would direct attention, here, further, to two important 
practical points to which Braun gives a prominent position; first, "The 
quantity of albumen has generally an intimate relation to the extent, 
intensity, and duration of acute Bright's disease, but not so constantly 
to the violence of the eclampsia ;" and, again, " The more acute the 
Bright's disease, the darker is the urine, and the more numerous, gene- 
rally, are the blood-corpuscles." 

Morbid anatomy throws no very new nor clear light upon the subject. 
In fatal cases, which are necessarily the most severe, we would naturally 
expect to find evidence, more or less distinct, of Bright's disease, in one 
or other of its stages or forms ; but this cannot fairly be held as indi- 
cating, with equal certainty, the pathology of those cases in which we 
venture to assume that the cause consists more in mechanical obstruction 
or peripheral irritation than in pathological lesion, and in which, pre- 
sumably, a fatal result would be less likely to ensue. Probably the 
result depends, then, in a great measure, upon the extent to which the 
structure of the kidney has become involved ; and if, in fatal cases, the 
hypersemic or exudative stage has rarely been observed, we may be sure 
that it is because these cases usually recover. If, on the other hand, 
the terminal stage, or stage of atrophy, has been reached, we cannot 
wonder that such irremediable disorganization should culminate in a fatal 
result, with or without convulsions. Besides the morbid appearances 



660 PUERPERAL ECLAMPSIA. 

which are characteristic of lesion of the kidneys, the only observations of 
importance which have been made are, that the lungs are constantly 
oedematous and sometimes emphysematous — the result, as is assumed, of 
the straining of the fits. The spleen is almost always enlarged, but this 
should not be mentioned as characteristic of the disease in question, as it 
is well known that enlargement of this organ is very usual, if not invari- 
able, during pregnancy and the puerperal state, associated, probably, 
with some compensated changes in the circulation. 

Some have supposed that uterine contractions have an important share 
in the etiology of eclampsia. That the disease may be manifested during 
pregnancy and after delivery shows clearly enough that this is not an 
essential condition, even although we may admit it as a possible cause. 
But, in truth, uterine action is much more likely to be the effect than the 
cause of eclampsia ; for, if there be any truth in the theory — to which 
some prominence has been given in previous chapters of this work — that 
deficient aeration of the blood is a cause of uterine action, prem.aturely 
or at the full term, we can have no difficulty in admitting that this con- 
dition exists, during the paroxysm of eclampsia, in a high degree. "By 
exciting pains," says Braun, " and increasing their strength, fits cannot 
be produced at will, nor even aggravated. For we have made the ob- 
servation, that, under a high degree of reflex sensibility, convulsions can- 
not be induced at will, at definite periods, by violent irritation of the 
uterus." We do not doubt this assertion, that fits cannot be produced 
at will ; but there are many cases on record of fits being produced, under 
such a degree of reflex sensibility as is here referred to, by attempts to 
introduce the hand into the uterus, during labor, for the purpose of turn- 
ing, or after labor, with the view of removing the placenta ; or, it may 
be, from emotional or other exceptional causes. This may, no doubt, be 
assumed to be attributable to uterine sensitiveness ; but we are inclined 
to agree, for anatomical reasons, with Dr. Tyler Smith, that the irrita- 
tion in such cases is more likely to spring from the vagina or the cervix 
uteri than from the nerves which are distributed to the body and fundus 
of the womb. On the whole, however, we must conclude that there is a 
ver}^ subordinate relation between uterine pains and ursemic eclampsia. 

The maternal and foetal mortality arising from this disease are subjects 
of great and obvious interest, since about thirty per cent, of mothers 
have hitherto succumbed to its effects, direct or indirect. A mortality so 
large as this must necessarily awaken in the mind an earnest desire for 
methods of treatment more effectual than any now at our command, and 
there can be little doubt that, if the death-rate from this cause is in the 
future to be materially reduced, it must be by a careful and earnest in- 
vestigation of pathological theories, and an observation, dictated by the 
same spirit, of clinical facts. The life of the foetus is certainly to be 
looked upon, in every case of puerperal eclampsia, as in great danger. 
This fact being admitted, it is by no means agreed as to what is the cause 
upon which it depends. The stoppage of the circulation in the maternal 
vessels of the placenta, as suggested by Kiwisch, can hardly account for 
this ; for, were it so, the danger would cease with the fit, whereas, the 
infant dies in about a half of all the cases, and almost always when the 
symptoms are severe and the attacks come on in rapid succession. There 



PROGNOSIS. 661 

is good reason to believe that the actual cause of death in such cases is 
an extension of the toxic influence from the blood of the mother to that 
of the child. On this point Braun observes : " If, after numerous 
ursemic convulsive fits, the child is born alive, a large quantity of urea 
is found in the blood taken from the umbilical cord ; but if it is born 
dead, we can, immediately after the birth, demonstrate the presence of 
carbonate of ammonia in the foetal blood." 

It has been said that, next to rupture of the uterus, eclampsia is the 
most disastrous affection which it is possible for us to encounter in the 
practice of obstetrics. There are certain questions of prognosis, there- 
fore, in regard to which much anxious speculation must necessarily arise. 
The points, as already remarked, which chiefly call for anxiety, are scanty 
secretion of urine, with an abundance of albumen (as when the urine 
solidifies on boiling), violent fits with short intervals, and profound coma: 
the converse of these gives good hope of recovery. The dangers, how- 
ever, of eclampsia depend, in no slight degree, upon the condition of the 
woman, and especially the period as regards pregnancy, labor, or child- 
bed, at which the symptoms first manifest themselves. When eclampsia 
occurs during pregnancy, it is almost always during the last three months 
that the first attack takes place, the viability of the child being in most 
cases undoubted. It rarely happens in these cases — and then only when 
the symptoms are moderate — that pregnancy is permitted to go on to its 
natural term ; and this alone, irrespective of toxnemic action, is apt to 
compromise the life of the child. In one-fourth of the cases, according 
to Braun, the albuminuria, or rather the uraemic or ammoniacal intoxica- 
tion of the blood,^ is sufficient, without the occurrence of eclampsia, to 
induce premature labor ; but, if the convulsive disorder should be devel- 
oped, the chances of mature gestation and the life of the child are still 
further reduced. 

When rhythmical uterine contractions, and other symptoms, have indi- 
cated the commencement of labor before the manifestation of the convul- 
sive phenomena, the effect which is produced upon that process is neces- 
sarily watched with much anxiety. In a certain number of cases, the 
obvious result is an acceleration in the progress of the labor, w^hen de- 
livery is sometimes completed with great rapidity. " The process of 
labor," says Baudelocque, " in these cases, seems even more rapid than 
in others, as the child has often been found between the legs of the 
mother, although an instant before, no disposition to delivery had been 
remarked." Inasmuch as no facts have hitherto been recorded which 
prove that the muscular system of organic life participates in the turbu- 
lent action of the muscles of animal life, it seems likely that the rapid 
expulsion in these instances is due rather to deficient resistance in the 
latter than to abnormal force of the former. It is quite possible, how- 
ever, that the pains may, by a reflex action upon the nervous centres — 
surcharged, as Barnes supposes, by an excess of nervous force — excite 
the expulsive efforts to such an extent as to induce this result. But this 
is widely different, as will be observed, from a morbid auxiliary force 

' Hammond and others have denied tliat tlie urea in tlie blood decomposes into car- 
bonate of ammonia. 



662 PUERPERAL ECLAMPSIA. 

arising from convulsive action. The result of delivery in effecting a di- 
minution in the frequency and violence of the paroxysms is universally 
acknowledged, and is recognized in practice by the rule which is admitted 
to be of universal application — to assist delivery as soon as the condition 
of the parts indicates that that stage has been reached when the passage 
of the child may be safely effected. 

It is a matter of dispute whether the eclampsia which develops itself 
for the first time after delivery, is, or is not, more dangerous than the 
other forms. Theoretically, one would think so, seeing that, uterine ex- 
citation and pressure on the renal veins being no longer in operation, the 
occurrence under such circumstances, might be held as indicating a more 
grave constitutional affection. But Pajot, Blot, and others, have strongly 
deprecated this assumption, and have stated, as the result of their expe- 
rience, that in these cases, the issue is on the whole more satisfactory. 
In those instances in which fits have come on before delivery, the com- 
pletion of labor, although it usually produces a marked amelioration of 
the symptoms, by no means places the woman out of danger. It has been 
observed by Blot that, putting aside the danger of repeated attacks of 
eclampsia, there is in such cases a special tendency to post-partura hemor- 
rhage ; and others have noticed that there remains a proclivity to the 
various inflammatory affections to which a parturient woman is liable, such 
as uterine phlebitis, peritonitis, pelvic cellulitis, and the like, the occur- 
rence of which is obviously favored by the derangements of the circu- 
latory system which repeated attacks of eclampsia necessarily engender. 

Treatment. — The earliest stage at which the question of treatment may 
offer itself for our consideration, is when the symptoms during pregnancy 
are such as to cause serious apprehension of an impending explosion. 
The most important of these are albuminuria, tube-casts in the urine, and 
oedema. Although a complete cure of albuminuria is very rarely ob- 
tained during pregnancy, something may, no doubt, be done in the way of 
moderating the disease, and preventing its passing into its higher and 
more incurable grades. It is, at least, possible, by the administration of 
ferruginous tonics and by a liberal diet, as recommended by Cazeaux, to 
ameliorate a watery or otherwise deteriorated condition of the blood, and 
a good general effect is often produced by the use of tepid and vapor 
baths. In order to prevent decomposition of the urea in the blood, or 
to neutralize the carbonate of ammonia already formed, it was suggested 
by Frerichs that tartaric acid, benzoic acid, or lemon juice should be 
regularly given, a recommendation which, although it has not yet received 
the assent of some eminent physicians, must be looked upon with interest 
as the necessary corollary to that author's proposition as to the patho- 
genesis of the disease. In every case, the function of the bowels should 
be carefully regulated, but purgation as a prophylactic measure, although 
strongly recommended by some, must be resorted to with caution, as there 
is a risk of thereby reducing the strength, which is already enfeebled. 
The quantity and microscopic conditions of the urine afford the best in- 
dications as to the necessity which exists for the use of diuretics. Braun 
recommends that, when exudation has taken place into the Malpighian 
capsules and the tubuli of Bellini and Ferrein, the cylindrical clots must 
be removed from them, and the formation of new ones prevented. If the 



TREATMENT. 663 

current of fluid proceeding from the vascular knot of the Malpighian bodies 
into the Malpighian capsules be strong, then the copious use of diluents 
is sometimes alone sufficient to wash away the cylindrical clots, and re- 
covery ensues. But, if the secretion of urine be very scanty, and uraemic 
intoxication threatens to come on, then the force of the current proceed- 
ing from the Malpighian bodies must be increased, and the cylindrical 
clots removed, for which purpose the acids (above mentioned), and the 
mineral waters of Sellers and Yichy are best adapted. Following the 
example of Frerichs, pills of tannin and extract of aloes may be used for 
restoring the normal tone. 

It has been proposed, with the view of obviating eclampsia and its 
dangers, that premature labor should be induced. Tarnier recommends 
that this should be done before the symptoms become urgent ; but we 
think that Braun's view is decidedly more judicious, when he insists that 
labor should only be provoked when the symptoms are such that the life 
of the woman is in danger. When the child is already dead, we are, of 
course, more justified in having recourse to this measure. When labor 
comes on, and there is reason to dread eclampsia, it has been recom- 
mended by Chailly that chloroform be employed with the view of warding 
ofi"the attack. 

In the treatment of eclampsia, in which the explosion has already 
taken place, our mode of procedure must necessarily differ, according to 
the period — pregnancy, labor or childbed — at which the fits develop 
themselves. But, as regards the treatment during the paroxysm the in- 
dications are the same in all cases, and consist mainly in doing what we 
can so to act upon the nervous system as to moderate central irritability, 
and reduce peripheral or reflex excitability to a minimum. Not many 
years ago, all cases of eclampsia, with the exception of the ansemic and 
hysterical varieties, w^ere treated upon one and the same principle, — that 
being free general blood-letting. The facts, however, which modern 
pathology has disclosed have completely altered the plan of treatment. 
Perhaps, in some quarters, the rejection of the lancet has been too ab- 
solute. Indeed, we incline strongly to this belief; for there are cases in 
which the constitution and temperament of the woman, and the violence 
of the attack, along with evidence of vascular tension of the brain, quite 
warrant us in supposing that venesection would afford the best chance of 
recovery. Still, it must be confessed that indiscriminate bleeding was a 
monstrous error, and that it would be better to do nothing at all than to 
bleed without selection of cases. Those who, in the present state of pro- 
fessional opinion, shrink most from the idea of the lancet, may, at least, 
in suitable cases, apply leeches freely to the temples. 

A remarkable effect is produced in many cases of puerperal eclampsia, 
by the administration of chloroform, ether, and other anaesthetic agents — 
an effect which, in some instances, quite surpasses our expectations. 
The approach of a repeated paroxysm, or symptoms such as make us 
dread the commencement of a first seizure, are a sufficient warrant to 
adopt this method of treatment. Respiration being much impeded, as we 
have seen, during the fit, it is proper at that time to withhold the chloro- 
form, so as not in any way to interfere with the function of respiration 
while the aeration of the blood is already so seriously interrupted. Anaes- 



664 PUERPERAL ECLAMPSIA. 

thesia, however, often has the effect of holding in subjection the pre- 
monitory symptoms, and so long as this result is undoubted, we may keep 
up the effect until the patient falls asleep, or the approach of stertor 
shows that the action of the drug can be safely pushed no further. 
When chloroform, which is the agent usually employed, fails to avert 
convulsions, it has very generally the effect of modifying them ; and we 
may infer that, by its action on the muscles of the mouth, throat, and 
larynx, the danger of suffocation, during the period of tonic spasm, is 
materially diminished. And there can be no doubt, as Barker observes, 
that chloroform alone has considerably diminished the rate of mortality 
in these painful cases. 

Chloral hydrate is another anaesthetic agent, which has of late been 
strongly recommended. The sedative and narcotic effects of this drug 
are well known, but it is not so generally understood that when it is 
pushed further, it produces an anaesthetic effect, under the influence of 
which a woman may be delivered without experiencing the slightest suf- 
fering. We can, Avithout hesitation, corroborate much of what has been 
advanced of late in regard to the marvellous effects of this druor in the 
treatment of convulsive diseases. When given in what we may call ordi- 
nary sedative doses, — not more than thirty grains, — its effect is safe, and 
in most cases efficacious ; but, should we think of giving larger and re- 
peated doses, we must bear in mind, that very alarming symptoms are 
occasionally produced, and that death has even been the result of what 
we might consider quite an ordinary dose. A number of cases have been 
of late recorded in proof of the efficacy of chloral in eclampsia. We ex- 
tract the following from the Grazette des Hdpitaux of Feb. 22,1873: 
" A woman of twenty-one, pregnant for the first time, who had suffered 
for fifteen days from oedema of the lower limbs and of the eyelids, from 
headache, somnolence, great weakness, and frequent calls to urinate, was 
admitted to the hospital of La Charite, under the care of M. Bourdon. 
On her admission, a large quantity of albumen was discovered in the 
urine. Three days passed without any appreciable change in her condi- 
tion ; but, on the fourth day, a violent attack of eclampsia took place, 
which lasted for ten minutes. During the period of resolution, an enema 
containing four grammes (a little more than one drachm) of chloral 
hydrate was administered, after which the patient almost immediately 
fell asleep. At the visit, on the following morning, labor had not com- 
menced. Foreseeing the probability of a renewed attack, M. Bourdon 
had two injections prepared, each containing four grammes of chloral. 
The first was administered at ten o'clock in the morning, just as labor 
had commenced. The second was given two hours afterwards. At three 
o'clock the labor terminated, without the woman having experienced the 
slightest pain. On the evening of the birth, a second eclamptic attack 
took place. A draught containing four grammes of chloral was at once 
administered ; she had a quiet night, and no fresh attack took place ; the 
oedema rapidly disappeared, and the patient left the hospital fifteen days 
afterwards." 

The effects of chloral are farther illustrated in a remarkable thesis by 
M. Charpentier,^ in which he contrasts the effects of the various reme- 

1 De rinfluence de divers traitements sur les acces eclamptiques. Paris, 1873. 



TREATMENT. 665 

dial agents which, np to this time, have been employed in the treatment 
of eclampsia. He, more particularly, compares the effect of treatment 
by the old method of bleeding, and the modern plan of aniTesthesia, with 
the following striking result, w^hich we quote, however, with the reserva- 
tion applicable to obstetrical statistics in general : — 

Mortality in cases treated by bleeding .... 35 per cent. 
" *' " ansestbetics . . .11 " 

"We must carefully avoid, moreover, the danger of adopting any par- 
ticular method of treatment to the exclusion of others. If we admit that 
throbbing carotids, and marked suffusion of the eyes and face after the 
subsidence of the fits, are exceptional symptoms, warranting blood-letting, 
w-e may, in like manner, concede that ice to the head may, in similar 
cases, be beneficial. Dashing the face and surface with cold water 
during the fit, as recommended by some, is always to be avoided ; for it 
is quite obvious that an excitation of this kind is likely to be followed by 
reflex convulsive phenomena. Sponging with warm water, or tepid 
vinegar and water, has been found useful ; and opium, in some form or 
other, has often been freely administered, both by the mouth and by 
enema, in cases in which the other methods of treatment have not ope- 
rated with sufficient rapidity. With reference to this drug, however, 
experience has shown that its administration in albuminuria in full doses 
is far from being free of risk. 

What may be called the obstetrical treatment of eclampsia involves a 
more particular reference to the stage at which the seizure occurs. The 
cases in which we would be justified in inducing premature labor are 
very exceptional; for it must be remembered that the usual effect of 
eclampsia is to bring on labor, so that we need not interfere in the pro- 
cess. Still, there certainly are cases where the gravity of the symptoms 
may call for prompt and decisive action. 

In eclampsia occurring during labor, our mode of procedure must, of 
necessity, be regulated entirely by the stage of the process which has 
been reached. There are, however, two preliminary points which it is 
necessary to have in view throughout : 1st, that on account of the ex- 
treme irritability of the nervous centres, we should avoid, as far as possi- 
ble, all sources of reflex irritation, and, above all, any unnecessary 
manipulation or digital examination; and, 2d, that although we recognize 
the importance of speedy delivery, we must be extremely careful, in 
adopting operative means for accelerating the process, to choose, if it be 
practicable, those only which are least likely to excite increased muscular 
action, whether of the voluntary or involuntary muscles. If the os is 
still closed and rigid, we content ourselves with cold applications to the 
head, and, at the same time, by means of chloroform or chloral, attempt 
to allay the nervous irritability, while we await the result of the natural 
process of cervical dilatation. If we wish to bring on labor, the safest 
method of provocation is to introduce an elastic catheter, in the m.'^nner 
described in a previous chapter. 

When the os is already partially dilated and dilatable, the treatment 
which is now recommended by almost all the best authorities, is to rup- 
ture the membranes, and after thus permitting the escape of the waters. 



66Q PUERPERAL ECLAMPSIA. 

narrowly to observe the subsequent stages of the process. Forcible 
dilatation of the os (^accouchement force') is a method of procedure which 
can scarcely be admitted as warrantable under any circumstances, and 
the same observation applies to the incision of the soft parts after the 
method recommended by Baudelocque. When the os is dilated, and the 
stage, consequently, has arrived at which the forceps may easily be 
applied, we hold the blades in readiness for immediate use ; but, even 
here, if the parts are anatomically in a favorable condition, it is better to 
leave the case for a time to nature. When the head has passed down- 
wards in the pelvis, and is pressing on the perineum, we need have little 
hesitation in using the instrument, should the condition seem urgent, or 
the labor begin to flag. After delivery, it is advisable that the removal 
of the placenta should not be long delayed, and the accoucheur should 
pay particular attention to the contraction of the uterus and the removal 
of clots. 

Should the convulsions persist after delivery, or should they then come 
on for the first time, full doses of chloral or opium, the administration of 
chloroform, cold to the head, perfect rest and quiet, and the emptying of 
the bowels, if necessary, by a simple enema, are the main points to be 
attended to. When the convulsions present the character of hysteria, or 
are of the so-called anaemic variety, the treatment must, of course, be 
modified, in the one case, by the addition of tae familiar antispasmodic 
remedies, and in the other, by the administration of stimulants with, sub- 
sequently, generous diet, and tonic restoratives* 



PUERPERAL FEVER. 667 



CHAPTEE XLIII. 

PUERPERAL FEVER AND ALLIED AFFECTIONS. 

Perplexing Nature of the Subject. — Puerperal Feyer: Does a Specific Puer- 
peral Poison really exist? — SJiould the term " Puerperal Fever" he retained? 
— Specicd Peculiarities of the Puerperal State. — Puerperal Septiccemia : Mode 
of Septic Poisoning. — Connection with certain Zgmotic Influences ; Erysipelas., 
Smallpox., Scarlet Fever., S^-c. — Connection icith Post-Partum Inflammations. — 
Puerperal Peritonitis; May exist independently of Puerperal Fever: 
Symptoms of an Ordinary Attack : of the more Severe form. — False Peritoni- 
tis. — Puerperal Metritis ; of less Frequent Occurrence : Symp)toms. — 
Uterine Phlebitis : Symptoms at first Obscure : Secondary Abscesses in 
the Later Stage : Tissues chiefly involved. — Vaginitis; Sthenic and Asthenic. 
— Inflammation of the Uterine Lymphatics. 

There is perhaps, in the whole range of obstetrics, no subject which 
the writer or teacher approaches with so profound a conviction of difficul- 
ties to be encountered, as that group of affections of the puerperal period 
to which the term Puerperal Fever has, w4th a somewhat loose significa- 
tion, been given. Beyond what he has learned from personal experience, 
he naturally turns to the literature of the subject, in the expectation that, 
by an analysis of the opinions expressed by the best authorities, he may 
succeed in formulating an intelligible nosological classification, reliable 
pathological data, and clear views of treatment. A very short experience 
will suffice to dissipate this delusion, so that he will soon recognize the 
difficulties of his position. It must be confessed, however, that the 
general tendency of the most recent contributions to this department of 
our literature has been to clear away many of the prejudices and errors 
of the past. That perplexities still remain is matter which can cause us 
no surprise, and we may be well content if w^e can recognize in the views 
of the present day theories which are more intelligible, more consistent 
with personal experience, and which point significantly to a solution of 
many problems which have vexed successive generations of able writers 
and experienced practitioners. 

When we employ the term " puerperal fever" in the singular number, 
the expression may be held to imply a belief in the existence of a spe- 
cific fever which runs a definite course to a crisis, after a period of 
latency, and is due to what we call a specific poison, in the same sense 
as we have a typhous, an enteric, and a variolous poison. This puer- 
peral poison was commonly assumed to be developed only in the puer- 
peral state, and communicable only from one puerperal Avoman to 
another. The first question to be determined then is — does any such 
specific poison exist ? or, in cognate terms — does any such disease occur 



668 PUERPERAL FEVER. 

as specific puerperal fever ? To these questions we do not hesitate to 
give a negative reply ; and, indeed, we confess to the existence of an 
impression that the term " puerperal fever" might be discarded, to the 
ultimate advantage of all concerned. The expression " post-partum 
fevers" has been suggested, and is in som.e ways to be preferred ; but, 
in the present and still unsettled state of the subject, it would, we 
believe, be dangerous to abolish old familiar landmarks, and, on that 
account, we are content to retain it, employing it, as it were, under pro- 
test, and in a guarded or limited sense. 

But, in rejecting the theory that there exists a specific puerperal 
poison, we are bound to state what views we propose to substitute for 
those discarded. Nothing, we think, is clearer than that writers have, 
under the head of puerperal fever, described a number of quite different 
aff'ections ; and if we attempt arbitrarily to state what of these are, and 
what are not the true fever, we will only contribute to the chaotic 
confusion in which the whole subject is involved. But, if we take a 
bolder and more comprehensive grasp of the subject, and admit that the 
symptoms which, for the sake of practical convenience, Ave call " puerperal 
fever" may arise from a number of different poisons or causes, and 
that the apparently specific character of the disease is due, not to any 
one specific thing in the cause, but to the peculiar physiological condition 
under which a puerperal woman lies — then we shall see some ray of 
lidit throuo;h the clouds. Of all the modes in which a serious fever 
may be generated in a puerperal woman, that by means of septic 
absorption, for which her condition at the moment offers peculiar 
facilities, is, we believe, decidedly the most frequent. Some go so far 
as to say that to these cases alone should the term puerperal fever be 
given. "Under the term puerperal fever," says Schroeder, "we place 
all such diseases of puerperal women as are caused by the absorption of 
septic matter, that is, organic substances in the process of decomposi- 
tion." If we could accept this view without reserve, the whole subject 
would become simplicity itself; but until certain facts connected with 
the germ theory of disease, and the presence and diffusion of bacteria 
in septic matter are cleared up, it would be premature to close the 
question. Matthews Duncan, who agrees with Schroeder, prefers the 
term of puerperal pyaemia ; but whether the word employed be septi- 
caemia, pyaemia, or ichorrhgemia, the essential points are — -a wound 
capable of absorbing, and a poison which is there absorbed. 

The idea of septic absorption by the surface from which the placenta 
has been removed is no new one. The theory of the present day is not, 
however, founded upon a mere surgical speculation, but has its basis in a 
series of brilliant investigations, including the demonstration of phlebitis 
and lymphangitis, of thrombosis and embolism by Virchow, and the 
well-known researches of Lister in regard to the action of septic poisons 
generally, and the influence produced by the development of bacteria. 
It is now known that poison introduced in this way does not generally 
act at the site of the placenta, but through the slight lacerations which 
occur in the tissues of the cervix, or through wounds which are the 
result of tearing of the fourchette, or fissures in any part of the vulvo- 
vaginal canal. The septic material may be introduced by the finger, 



ZYMOTIC INFLUENCES. 669 

by instruments, by infected sponges, or dressings, possibly through the 
atmosphere ; and, in a limited number of cases, Avhere unhealthy action 
has taken place in the wounds, absorption takes place of decomposing 
maternal parts by the surrounding living tissues. Cases of puerperal 
pyaemia or septicaemia, therefore, may be divided into two classes, 
according as the mischief arises from the patient herself (^auto genetic'), 
or is introduced into her system from others, or, at least, from some ex- 
ternal source (lietero genetic). 

But, while we believe that this affords by far the most satisfactory 
solution of the question in regard to most cases, it seems to us equally 
clear that a fever, apparently identical in its symptoms and course, 
may arise from other poisons and other causes. Erysipelas is one of 
the most apparent of these, so much so, indeed, that they who believe 
in the existence of a specific puerperal poison have even surmised that 
the two poisons were identical, a conclusion which is not altogether 
inconsistent with the septicc"emic theory, for the connection of erysipelas 
and pyemia or septicaemia is only too familiar in the practice of surgical 
hospitals. The relation between outbreaks of erysipelas and the pre- 
valence of puerperal fever has been placed beyond all dispute by the 
unfortunate experience acquired by the opening of Lying-in Wards in a 
general hospital, as the results were so disastrous that such w^ards are 
now very properly abandoned. In considering this connection of ery- 
sipelas and puerperal fever, we must not allow ourselves to be misled by 
the absence of redness of the skin, as it is well known that the most 
malignant forms of erysipelas may fail to present this sign of the pre- 
sence of the poison. Nor should we allow ourselves to doubt the reality 
of this connection on meeting with certain cases of erysipelas which run 
their course in puerperal patients, without any symptoms of special 
gravity. 

Again, it is manifest that women, during the puerperal period, may be 
so circumstanced as to come within the range of the poison of any of the 
specific fevers. Take the most familiar illustration, scarlatina ; and, we 
ask — Is this fever scarlatina pure and simple ; or is it what we call puer- 
peral fever, modified more or less by the action of the specific poison ? 
That this is at the present moment a point of special significance, is clearly 
indicated by the interesting debate which recently occupied the attention 
of the Obstetrical Society.^ In regard to the question which we have 
proposed, the balance of opinion was in favor of the view to v^hich we 
adhere — that although the scarlatina poison may produce in puerperal 
women an ordinary attack of scarlatina and nothing more, this is not the 
rule, but a rare exception. What we are apt to overlook in discussing 
this whole subject, is the peculiar condition of the woman, no less in the 
condition of her blood, than in the newly organized function of lactation 
and uterine involution. Need we wonder then, that, when a woman so 
placed is attacked with scarlatina, these facts should affect the action of 
a special poison, and give to the disease which is engendered more or less 
of the features of what is called puerperal fever? It matters little in 

1 On tlie Relation of Puerperal Fever to the Infective Diseases and Pyaemia. Trans- 
actions of the Obstetrical Societv of London. Vol. xvii. 1876. 



670 PUERPERAL FEVER. 

practice whether we say that it is modified scarlatina, or modified puer- 
peral fever, so long as we recognize the affinity which subsists between 
the two. — Various circumstances tend to disguise the presence of scarla- 
tina in puerperal women ; and, indeed, it not unfrequently happens that 
it is only after the patient has died that the subsequent occurrence of well 
marked scarlatina in the family convinces us of its real connection with 
the fatal case of puerperal fever. In particular, we may have the case 
running its course with extraordinary rapidity and violence, w^ithout any 
trace of eruption, or with such trivial and transient patches of redness 
that we can place no reliance on their appearance ; and such patches are 
particularly confusing in the differential diagnosis, as red eruptions seem 
to occur occasionally in cases of septicaemia, apart from scarlatina. In 
like manner, the usual soreness of the throat may be absent, or at least 
quite destitute of its typical characteristics. The facts connected with 
infection are likewise apt to mislead us. A previous attack of scarlatina 
does not afford to the puerperal woman the same degree of security against 
its recurrence which it does to others ; and the infection seems occasion- 
ally to remain latent in pregnant women for some time, so that when the 
disease breaks out, immediately after labor, it may seem from the sur- 
rounding circumstances as if any recent infection were quite impossible. 
This outbreak of an attack of scarlatina, coincidently with the occurrence 
of labor, is somewhat analogous to the " surgical scarlet fever," which 
sometimes appears after operations ; but the very slight disturbance usual 
in the surgical variety, and the very alarming violence habitual to the 
puerperal form, may be taken as evidence of the over-ruling importance 
of the conditions incident to the puerperal state on which we have already 
so strongly insisted. 

In precisely the same manner the other specific fevers may induce an 
aff"ection which, whether it retains more or less of the characteristics of 
the disease from which it has been engendered, usually gives clear evi- 
dence of the puerperal type of febrile disease. Yariola and typhus may 
thus take their course, but the puerperal state fearfully augments the 
risk ; and we have lately seen an extremely painful case in which a case 
of undoubted enteric fever, occurring in the puerperal period, passed into 
a condition which it was impossible to distinguish from the more familiar 
septicsemic variety. The poison of Measles and Diphtheria may operate 
in the same way on puerperal women, although we may only be able to 
recognize the special disease by a full consideration of all the surround- 
ings of the case. 

There is another class of cases in which the earliest symptoms are 
clearly inflammatory. In these, the symptoms and course of the malady 
present, as a rule, points of contrast with puerperal fever which are very 
striking. Be it well understood that we do not speak now of inflamma- 
tions which arise in the course of the more common variety of the fever. 
These we may, without hesitation, refer to the adjacent septic action. 
But when the patient, by exposure to cold or imprudence of any sort, 
becomes affected with an inflammation which attacks the tissues of the 
peritoneum, the womb, or the neighboring structures, the inflammation, 
thus or otherwise engendered, sometimes runs to a fatal result, giving rise 
the while to symptoms which, if not identical with, it would be injudicious 



ALLIED AFFECTIONS. 671 

to separate from those of puerperal fever. Such cases, indeed, may often 
be regarded as milder or more chronic forms of the autogenetic variety 
of puerperal septiciiemia. 

We may thus tabulate the views here expressed : — 

VARIOUS FORMS OF FEBRILE DISEASE USUALLY CLASSED UNDER 
THE NAME OF PUERPERAL FEVER. 

1. Puerperal Septic.i;mia or Py.^mia : including 

a. (Autogenetic). Cases arising from the infection of the patient by the absorp- 
tion of her own secretions through abrasions, Avonnds, &c. ; by the reten- 
tion of clots or portions of placenta in the uterus ; or by the absorption 
of products resulting from inflammatory disease. 

h. (Heterogenetic) . Cases arising from the infection of the patient /ro/w icithout, 
chiefly from other cases of septicaemia, directly or indirectly. 

2. Puerperal Erysipelas : Often present in epidemics of so-called puerperal fever, 

and communicated from one patient to another ; also communicated at times 
to puerperal women from ordinary forms of erysipelas. 

3. Puerperal Forms of Scarlatixa and other Specific Ixfectious Fevers, the dis- 

tinctive forms of the special diseases being often masked, and the illnesses 
usually characterized by great virulence and intensity. 

Under the designation of "Allied Affections," it is well that we 
should consider at this place those local inflammatory affections, which 
although in their simple form not entitled to rank as fevers, are, as we 
have said, apt to run into a peculiar and fatal febrile condition. In their 
simple form, or early stage, we prefer to call them " post-partum inflam- 
mations." 

Peritonitis — Puerperal Peritonitis. — This, as one of the most fre- 
quent inflammatory sequelae of delivery, and the most familiar accom- 
paniment or complication of puerperal fever, is the affection which natu- 
rally is the first to attract our attention. Inflammation of the peritoneum 
may, as we have said, exist and run its course without any manifestation 
of symptoms indicating the operation of a morbid poison — in other words, 
puerperal peritonitis may exist as an aftection distinct from puerperal 
fever. In some cases it affects a small portion only of the membrane in 
the pelvic region : when it may give rise to a more chronic affection 
(Pelvi-peritonitis), which will fall to be considered in a subsequent 
chapter. 

An ordinary attack of peritonitis almost always comes on within a 
week of the period of delivery. The patient is seized with a rigor, of 
greater or less severity, followed by heat of skin, acceleration of the 
pulse, and other febrile symptoms. At the same time, she complains 
of pain in one spot — usually in the pelvic region — whence, if violent in 
degree and unchecked, it may pass over the whole of the abdomen. 
Imprudence during the period of convalescence may no doubt lead to 
the development of simple peritonitis, but this is less frequently the 
case than we might have anticipated. The sooner after labor the 
symptoms are manifested, the more serious is our prognosis as to the 
issue of the case ; and, in a large proportion of cases, if not checked by 
appropriate treatment, it is apt to run rapidly to a fatal termination. 
That portion of the abdomen which is the seat of the inflammation has 
often been observed to be swollen and tumid. The pulse is quick, wiry. 



672 PUERPERAL FEVER. 

and incompressible, and rises in frequency as the inflammation extends ; 
the tongue is not usually much altered in the early stage. Nausea and 
vomiting are of frequent occurrence as the disease progresses, and the 
swelling and tumefaction of the belly become more marked. The bowels 
are obstinately costive, and, in the more advanced stages, the patient 
lies on her back with her knees drawn up. 

To this, if the symptoms are unchecked, succeeds a second stage, 
which it is sometimes impossible to distinguish from puerperal fever. 
There is now a decided change in the character from the inflammatory 
to the asthenic type. There is a marked alteration in the countenance, 
a pitiful appearance of ghastly distress. The belly swells still further 
and becomes tense, with great aggravation of the suffering, so that the 
patient can now no longer bear even the pressure of the bedclothes. 
If the lochial discharge has not been previously arrested, it now becomes 
fetid, and the breasts become flaccid. The tongue is dry and often 
furred, and the unhappy patient suffers from excessive thirst. The 
violence of the vomiting in some degree subsides, but the patient is now 
attacked with diarrhoea, which is often violent and uncontrollable. The 
extremities become cold ; the surface of the body is bedewed with a 
clammy perspiration ; and low muttering delirium sets in. With these 
symptoms, or even at an earlier period, there is a remission or cessation 
of the pain, which sometimes gives rise to fallacious hopes in the mind 
of the patient and her friends. Hiccough, picking of the bedclothes, 
and delirium are the immediate precursors of death. Occasionally, a 
rapid metastasis of the inflammation takes place, even after an abate- 
ment of the symptoms has led us to hope that the danger had passed. 
The inflammatory process may thus blaze out afresh and with equal 
violence — ^in the pleura, for example — and we have known a second 
metastasis take place, first to one pleura, and subsequently to the other. 
Such facts point to the close resemblance of this phase of the disease to 
septicaemia. 

Nor is it of any great moment to determine where the one variety 
ends and the other begins. If we admit the fact that puerperal fever 
may be generated from various sources, may we not assume it as proba- 
ble — to say the least — that it may be developed in the course of an in- 
flammatory disorder, which is so frequently its accompaniment? 

But peritonitis occurs likewise as a complication of nearly all forms 
of puerperal fever. The symptoms are, from their earliest development, 
of a violent, if not of a malignant type ; the pulse is, from the first, 
extremely rapid and thready, about 140 in the minute, and destitute of 
any force. Instead of there being constipation — which is the prevailing 
characteristic of simple peritonitis — diarrhoea sets in early, and the case, 
thus passing over, as it were, the initiatory stages of the disorder, plunges 
the patient at once into a state from which recovery may seem to be all 
but hopeless. The form is of a low type from the first, and the abdomi- 
nal tumefaction commences at an earlier stage. It has also been re- 
marked that, in this variety, the pain begins in the region of the dia- 
phragm, and radiates from that point, instead of from the pelvic region, 
over the whole peritoneal surface — and that with much greater rapidity 
than in the other form. The absence of excessive tenderness, which we 



PERITONITIS. 673 

expect in peritonitis, is often very complete, and the inexperienced may 
thus be misled in the diagnosis. It would appear, also, that, in the 
more serious form, there is a remarkable difference in the exudative 
effects of the inflammatory action. In ordinary peritonitis, adhesive 
lymph is poured out, as an attempt at reparation on the part of nature, 
barring the further progress of the malady by gluing the parts together. 
But, in the more serious and fatal form, which has most likely its origin 
in contagion, the lymph is not adhesive, the inflammation is not circum- 
scribed, and both Hulme and Leake found that, in these cases, the peri- 
toneum is softened to such an extent that it actually seems gangrenous. 

False Peritonitis — Acute Tympanites. — We place these affections to- 
gether, not from any idea of their identity, but because they are condi- 
tions which may seriously embarrass the practitioner who may not be aware 
of the possibility of their occurrence, or, what is worse, may lead him, 
through a false diagnosis, to adopt methods of treatment which are the 
reverse of beneficial. The term False Peritonitis implies abdominal pain 
w^hich is not inflammatory in its origin. It is, in all probability, due, 
either to intestinal irritation, or to some neuralgic affection of the abdo- 
minal walls in consequence of over-distension : in some cases it may be 
due to rheumatism. The severity of the pain, the acceleration of the 
pulse, and the other constitutional symptoms to which it gives rise, may 
lead, very possibly, to a hasty conclusion that true peritonitis is the dis- 
ease with which we have to deal. It would seem, however, from the de- 
scription given by Dr. Ferguson of a malady which came constantly 
under his notice in the year 1827 and the early part of 1828, and to 
which he gave the same name, that this comparatively trivial affection 
may possess something of an epidemic character, although it may be 
relieved by the simplest remedies. The treatment which has been found 
most efficacious is the administration of a full opiate. 

The name Acute Tympanites was given by Dr. Ramsbotham to an 
affection which he himself had frequently observed, which he believed 
to be a variety of the intestinal irritation of Marshall Hall, and which 
is particularly interesting in this respect, that it very closely resembles 
ordinary puerperal peritonitis — so closely, indeed, that, to judge from the 
description given by Dr. Ramsbotham of the symptoms, it must be a mat- 
ter of no small difficulty to distinguish the two affections, excessive tym- 
panites being one of the most marked features of puerperal fever. We 
are inclined to think, however, that he has given too much prominence to 
this affection as an independent puerperal disorder. 

Puerperal Metritis. — This is an affection which, uncomplicated, is of 
much less frequent occurrence than peritonitis. Ilysteritis, or Metritis, 
under the ordinary childbed conditions, involves the idea of an acute in- 
flammation, attacking tissues which are the seat of a very peculiar process 
ofinvolution, a part ofthe physiological phenomena of gestation. In a chronic 
form, it is by no means of unfrequent occurrence ; but, under such circum- 
stances, the result is not usually fatal. In the acute form, however, it has 
been observed to be very fatal, and to terminate, as in the case of perito- 
nitis, with all the horrors, apparently, of puerperal fever. In the mode 
of access, it does not differ materially in its symptoms from peritonitis. 
The pain, however, is in this case referred more particularly to the hypo- 
43 



674 ' PUERPERAL FEVER. 

gastric region, where the uterus may be distinguished of larger size, and 
sometimes harder, than is usual at the period. On a digital examination 
by the vagina, the nature of the case is further revealed, by the heat and 
tenderness of the os uteri. This has been more frequently observed as 
a consequence of severe or protracted labor than the peritoneal variety ; 
and, in those cases in which a fatal result has ensued, extensive disor- 
ganization of the uterine tissues has been remarked. 

That an inflammatory aifection, having its seat in the tissue proper of 
the uterus, may occur in childbed, we cannot dispute. But it may well 
be doubted whether many of the cases which have been referred to this 
category ought not rather to have been classed under a different head — 
Uterine Phlebitis. To no one do we owe more, as regards the elucida- 
tion of this subject, and a painstaking investigation of the principal phe- 
nomena upon which it depends, than to Dr. Robert Lee. Opinions are, 
however, on this matter, far from harmonious. It is easy to conceive 
that, when the structure of the uterus is the seat of inflammatory action, 
it can be no simple matter to determine, during life, what share the various 
tissues of the organ take in the morbid phenomena upon which the symp- 
toms depend. If the evidence is not altogether clear, many facts combine 
to show that there are, in a considerable number of cases of puerperal 
fever, indications of great significance, which it is difficult to explain on 
any other hypothesis. The earlier symptoms may, indeed, admit of a 
different interpretation. At first there is more or less of rigor, followed 
by pyrexia, and accompanied with pain in the hypogastric region, gene- 
rally referred more particularly to the iliac or ischiadic region of one side. 
The condition of the lochial and mammary secretions varies, although 
the general tendency is to the arrestment of both. These symptoms are 
usually developed within three or four days after delivery : diarrhoea — 
and not, as in the case of peritonitis, constipation — is a prominent feature 
in the case. A tympanitic condition of the abdomen is also uniformly 
observed, but the general tenderness, and other symptoms of peritonitis, 
are, for the most part, absent. The pulse, is generally over 120, and 
sometimes reaches 150, and is soft and compressible from the first. 
Should resolution take place at this stage, it would, we believe, be im- 
possible to say whether it has been a case of metritis, of phlebitis, of 
circumscribed peritonitis, or of any of these combined. 

If the case goes on, however, — and, sometimes, in the worst form, 
very shortly after the seizure, — a new class of symptoms is developed, 
which alone can be held as pathognomonic of phlebitis, and of the blood 
poisoning, which has probably been the result of traumatic septicaemia. 
The patient now complains of pain in various parts of the body, — most 
frequently in the neighborhood of the joints. In these situations, swell- 
ings and erysipelatous blushes appear, indicating the formation of 
secondary abscesses ; or the abscesses may form internally either in the 
neighborhood of the uterus, or in distant organs, — such as the lungs, 
liver, or kidneys, — and occasionally they are imbedded deeply in the 
substance of the muscles. In some cases, the eye, and more commonly 
the left eye, has been the seat of violent destructive inflammation. Such 
formations of pus, if neither violent nor extensive, may, in some fortunate 
instances, be looked upon as critical, and in that sense favorable ; but, 
unfortunately, experience points to a contrary result. In the worst 



VAGINITIS. 675 

cases, which have been observed in various epidemics, the tendency of 
the inflammatory process to attack the joints has been uniformly well 
marked, and the fearfully rapid nature of the action, the enormous quan- 
tity of pus which is formed, and the destruction of the articular car- 
tilages, have only too frequently been demonstrated in post-mortem 
examinations. 

Puerperal phlebitis may extend to the proper tissue of the uterus, and 
also to the peritoneum — in which latter case the symptoms of peritoneal 
inflammation are superadded to those which more vaguely indicate in- 
flammation of the uterine veins. It would appear that, in a certain 
number of fatal cases, the action is confined to the uterus, — a result 
which may easily be explained by supposing that death had taken place 
before the toxaemia had time to produce its distal effects, in the produc- 
tion of abscess, etc. 

Vaginitis, — A protracted labor, in which the presenting part of the 
child has been allowed to remain too long in the same situation, may give 
rise, by pressure, to very severe inflammation, and, even to sloughing of 
the walls of the vagina. In so far as the latter form is concerned, its 
results have already been incidentally referred to, and consist mainly of 
vesico- vaginal fistula, and of contraction of the vagina, or the formation 
of septa or bands, which ultimately constitute serious impediments to the 
progress of labor. There is, moreover, too much reason to believe that 
the injudicious or unskilful use of instruments is a fruitful cause of this 
complication, and, indeed, rash operativ^e procedure of any kind is not 
unlikely to produce it, by the actual mechanical violence which is thus 
inflicted. Inflammation of these tissues, however, even when it does not 
proceed to gangrene, may prove a very serious complication, and, by the 
constitutional irritation which it engenders, may give rise to serious ap- 
prehension. The risk, in such a case, is not only from the effects of local 
lesion, leading to septic action and puerperal fever, for even if this be 
averted, the fire which is thus kindled may spread, and, by involving the 
uterus, the peritoneum, &c., may give rise to the panic of a general con- 
flagration. It may, with reason, be objected, that an inflammatory affec- 
tion of this kind should not be included under the "-eneric designation of 
puerperal fever ; but, while we admit the force of the observation, we 
recognize between it and the other inflammations, as between those and 
puerperal fever, such intimate pathological affinities, that we have no 
hesitation in placing them in juxtaposition. Inflammation of the vagina 
is accompanied with much swelling and tumefaction of the neighboring 
parts, and with an alteration in the nature of the discharge, which gives 
rise to more or less of fetor. The orifice of the urethra is involved, so 
that there is extreme difficulty or impossibility of micturition, and the 
condition of the vulva is such as to give rise to great annoyance, — these 
symptoms, taken together, affording a ready means of diagnosis. 

An affection, scarcely less important than this, although it has less 
direct connection with the subject of puerperal fever, is inflammation of 
the vagina, of an asthenic type, similar to what occasionally occurs in 
the course of typus or other fevers. In this case, the whole vagina, 
without any obvious local cause, is quickly involved in inflammation of 
the type alluded to, which defies all treatment, local or general, and 
rapidly passes into gangrene. The result of such violent and rapid 



676 PUERPERAL FEVER. 

action has been to involve the recto-vaginal septum in almost its whole 
extent, and to cause such a degree of vesico-vaginal inter-communication 
as to defy even the improved remedial appliances of modern surgery. 
And, even when the destructive process has not involved those viscera, 
we have seen such implication of the perineal tissues, and consequent 
contraction, as to leave a bare exit for the menstrual flux. 

This is, of course, supposing that the patient survives. Unfortunately, 
however, when the inflammation assumes this type, recovery can scarcely 
be looked for, and the patient succumbs, either from the action of the 
morbid poison, from an extension inwards of the inflammation, or more 
frequently still, from these two causes combined. The extremely rapid 
and feeble pulse, with cold extremities, and the offensive lochial discharge, 
indicate the type of the case ; and soon the clammy surface, the anxious 
countenance, with hiccough, subsultus, and delirium, show only too clearly 
that the end is at hand. 

Another variety of puerperal inflammation is that form of the process, 
in which it has its seat in the Uterine Lymphatics. This was first 
described in France by M. Dance, and has since that time attracted the 
attention, both in this country and abroad, of most systematic writers. 
The presence of pus within the vessels of the lymphatic system has been 
repeatedly demonstrated ; but in so far as the symptoms are concerned, 
it would seem to be impossible to distinguish the affection from some 
others which have been described, and especially from uterine phlebitis. 
But, besides this, it is extremely improbable that, in the condition of the 
uterus at the puerperal period, angeioleucitis should be present without 
involving, more or less, the other tissues. And, perhaps, the converse 
may equally hold good — that inflammation originating in other tissues 
may very readily pass to the lymphatic system. Although attempts 
have been made to show that the worst results of puerperal fever spring 
from inflammation of the lymphatics, Yirchow has proved that lymphatic 
thrombosis is a favorable symptom in so far as it bars the transport of 
infected material. 

The various affections above detailed by no means embrace all the 
complications which may exist along with puerperal fever, whether in 
the relation to it of cause or of eff"ect. And if we were to attempt an 
analysis of what may be called anomalous cases, we would but complicate 
still further a subject which we are specially anxious to put in as simple 
a light as possible. Some have placed phlegmasia dolens in this cate- 
gory, and in the cases in which that affection has been observed along 
with puerperal fever, it may Avell be supposed that both are the result of 
the same poison. It is quite obvious, however, that puerperal fever can- 
not be considered as a result of phlegmasia dolens ; otherwise, the latter 
affection would be looked upon with much apprehension, instead of in- 
volving, as it does, a favorable prognosis. The general state of the 
system in childbed, to which we have already so frequently referred, is 
singularly favorable to an extension of inflammatory action which has 
already been commenced. It need scarcely, therefore, cost us a moment 
of surprise, when we find the local inflammations of the puerperal state 
blazing out with a violence which defies extinction, and rapidly assuming 
the asthenic or adynamic features, which are held to be characteristic of 
the most fatal form of puerperal fever. 



CONTAGION. 677 



CHAPTEE XLIY. 

PUERPERAL FEYER, &c.— (Continued.) 

Question of Contagion: Septiccemic Infection: Other Specific Poisons. — Are In- 
flammatory Cases Contagious ? — History of Epidemics. — Symptoms of Puer- 
peral Fever. — Morbid Anatomy: Malignant and other Varieties Contrasted: 
Lesions of other Organs: Pathological Appearances no Indication of the 
Virulence of the Attack. — Evidence of a Change of Type in Puerperal Fevers. 
— Treatment : All Varieties to he Treated as if Contagious : Recorded Results 
of Blood-letting and Purging: Gooch's Treatment : Connection of Metastatic 
Inflammation with Thrombosis and Embolism: Uterine Phlebitis: Purulent 
Formations: Effect of Emetics ; Calomel and Opium; Turpentine^ Blisters, 
and External Applications ; Tonic and Stimulant TreatmeJit : I'apping the 
Peritoneum: Prophylactic Treatment: Cleanliness: Use of Antiseptics. 

Before going further in our attempt to describe the symptoms and 
treatment of the fevers of the puerperal state, it is proper that the 
subject of contagion should receiv^e that careful attention which its 
important practical bearing demands. For purposes of convenience, 
we may divide the question of contagion into two parts — 1st, Is 
puerperal fever contagious? — and, 2d, Are the "allied affections" 
contagious, and, if so, to what extent? Some confusion may here 
arise as to the meaning of the word Contagion. "By a contagious 
disease," says Schroeder, " is meant one in which a specific poison is 
produced within a diseased organism, and which, transferred to other 
individuals, always produces the same specific disease, such as measles, 
scarlatina, smallpox, syphilis, &c." It will at once be noticed that if 
we concede that puerperal fever is not due to a specific poison, and at 
the same time admit the accuracy of Schroeder' s definition of the word, 
we necessarily come to the conclusion that puerperal fever is not a 
contagious disease. Such hair-splitting in regard to the meaning of 
words tends more frequently to confusion than to precision, and pre- 
ferring, as we do, the word "contagious" to "communicable," we employ 
the former in its broader and more colloquial signification. 

In reply, then, to the first part of the question, we hesitate not 
for a moment to say that puerperal fever is contagious. Accord- 
ing to Barker, there have been described, since 1740, upwards of 
two hundred epidemics of puerperal fever, and it would, perhaps, be 
sufficient, in most minds, to establish the truth of our proposition, 
carefully to peruse the details of one or two of these outbreaks, when 
the facts will be seen to be utterly irreconcilable with any other theory. 
Many observations, in themselves conclusive, are on record. " Two 
medical men," says Dr. Tyler Smith, " brothers and partners, attended 



678 PUERPERAL FEVER. 

in the space of five months twenty cases of midwifery. Of these, four- 
teen were affected with puerperal fever — a fatal result ensuing in eight 
cases. The only other known death from puerperal fever, in the same 
town, within the period named, occurred in the case of a patient 
attended by a medical man who had assisted at the post-mortem of 
one of these puerperal patients. After this disastrous period, the 
two brothers relinquished all their midwifery engagements for one 
month, in which time five of their cases were attended by other practi- 
tioners, and no instance of fever occurred in the course of that month. 
They then returned, and several fatal cases again happened. . . . Mr. 
Roberton, of Manchester, relates, perhaps, one of the most cogent 
instances of contagion and fatality on record. In the space of one 
calendar month, a certain midwife attended twenty cases belonging to 
a lying-in charity : of these, sixteen had puerperal fever, and all died. 
The other midwives of the same charity, working in the same district, 
attended, in the same time, 380 cases, none of whom were affected with 
puerperal fever. In another large town, containing many thousands of 
inhabitants, and numerous medical men, fifty-three cases of puerperal 
fever occurred. Of these, no less than forty happened in the practice 
of one medical man and his assistant." 

If these facts do not suffice to establish beyond all question the 
doctrine of contagion, we would refer the reader to the works of 
Gooch, Routh, and Semelweiss, for evidence which appears to us to 
be unanswerable. Those who oppose the contagious view attempt 
to account for such facts as have been quoted, by exaggerating the 
importance of epidemic influences. That epidemic and atmospheric 
influences bear upon the question we do not dispute, but that these 
will enable us to account for such cases as have been mentioned we 
cannot for a moment believe. The well-known occurrence of sporadic 
cases has also been urged against the doctrine of contagion. It is, 
however, so easy to account for such cases, by the septicsemic theory, 
that we may pass this subject by without further comment. There are 
other influences which may well be assumed to have some share in the 
manifestation of the disease, — 3uch as the general health, temperament, 
and constitutional vigor of the patient, and the circumstances under 
which she is confined. It has been repeatedly noticed that depressing 
mental emotions exercise a very marked effect, so that women who have 
been seduced are more prone to the disease than others. " Several of 
the worst cases I have seen," observes Dr. Churchill, " were mainly 
attributed to this cause." 

The doctrine of contagion is, in regard to septicsemic puerperal fever, 
now all but universally received ; but in regard to some of the varieties, 
and the allied inflammatory affections, the question presents itself for 
• solution under conditions of greater difficulty. We have already ex- 
pressed our opinion that, although scarlatina may run its course in a woman 
who has been recently delivered, without the development of any marked 
symptoms beyond those of the specific fever, such cases very frequently 
pass into a condition which is identical with puerperal fever. But, be- 
yond this, we are convinced that from the contagion thus developed, puer- 



CONTAGION. 679 

peral fever may be again and again reproduced ; and, if we are right in 
this, the same remark will apply to the other specific fevers. 

One or two examples, illustrative of the manner in which puerperal 
fever is generated by different poisons, may here be adduced. A patient 
Avas admitted by some oversight, into the wards of the Dublin Lying-in 
Hospital, while laboring under typhus fever ; but the error having been 
discovered, she was removed in a few hours. In the beds on the right 
hand and the left of this woman were two lying-in women ; both were 
attacked with puerperal fever, and both died. " In another case," says 
Dr. Tyler Smith, " a medical man was in constant attendance upon a 
patient suffering from gangrenous erysipelas, and, between the 8th of 
January and the 22d of March, attended the labors of ten women ; all 
had puerperal fever, and eight of the patients died. This was in a town 
of moderate size, and no other patients in the place were known to have 
had puerperal fever. A remarkable instance to the same effect, is related 
by Dr. Ingleby. Two practitioners attended a post-mortem,, where the 
patient died from this disease. The first was summoned, in one direction, 
to a midwifery patient, who was attacked with puerperal fever ; the other 
attended two cases in succession, both of whom were seized with the same 
disease." The enormous mortality which at one time prevailed in the 
Lying-in Hospital of Vienna, gave rise to the belief that the disease was 
propagated by means of poison communicated by students who had re- 
cently been engaged in dissection, and the observations of Dr. Semelweiss 
strongly corroborated the supposition. It seems to us, however, that this 
has been considerably exaggerated as a means of generation of the poison, 
as the evidence upon which the assumption rests is derived mainly, though 
not entirely, from lying-in hospitals. Medical students are proverbially 
careless in these matters, unless they are under strict supervision ; but 
it is somewhat strange that observation, extended over many years of the 
practice of a large lying-in charity, where the women were delivered by 
students and midwives exclusively at their own homes, has failed, in our 
experience, and in that of others, in recognizing any such marked septic 
influence as Semelweiss would have us anticipate. That the cadaveric 
poison has, undoubtedly, caused puerperal fever, is, however, quite enough 
to demand from every one the strictest precautions which can be devised, 
in order to avert so dreadful a calamity. With regard to post-mortem 
examinations, the danger is probably very much increased by the nature 
of the disease which has caused the death, puerperal fever and perito- 
nitis, erysipelas, and the specific fevers being apparently more dangerous 
than other forms of disease. 

In regard to the cases which may be supposed to be of inflammatory 
origin, the case is different. A simple inflammation is not communicable : 
but when a case, at first simple, runs a rapid course, and ends fatally with 
the symptoms, let us suppose, of peritonitis and metritis combined, he 
would be a bold man who would venture to assert that there was no 
danger. We have never seen any reason to doubt that such a disease 
is communicable, and we have never been able to discover any essential 
diff'erence between it and the other varieties. There is a general impres- 
sion, however, that the autogenetic cases, and those which run a mild 
and more chronic course, are less apt to give rise to contagion than the 



680 PUERPERAL FEVER. 

others. For the practitioner the only safe rule is to look upon all cases 
with suspicion, and to adopt the most stringent and careful precautions 
in every serious inflammatory case, lest he should become the means of 
carrying death to his patients. 

Puerperal fevers have been met Avith under different forms, and as we 
might anticipate, the intensity or concentration of the poison is attended 
with a coresponding virulence in the symptoms. But, besides that, it 
would seem that in particular outbreaks of the disease, the cases resemble 
each other in manifesting certain complications, chiefly inflammatory. 
But instead of attempting to classify the difl"erent forms by talking of 
Malignant Fever, Hidrotid Fever, and the like, we prefer to make the 
attempt to treat the whole matter in a more comprehensive and simple 
manner. The older writers describe this afi'ection as " childbed fever." 
The term " puerperal fever" dates from the beginning of last century. 

About 1746 a dreadful epidemic of puerperal fever appeared in Paris, 
a very accurate and full description of which was given by Malouin.^ 
The mortality was so frightful, that at the Hotel Dieu scarcely a single 
patient recovered. "The disease usually commenced with diarrhoea; 
the uterus became dry, hard, and painful : it was swollen, and the lochial 
discharge Avas irregular. The women then experienced pain in the 
bowels, particularly in the situation of the broad ligaments ; the abdo- 
men was tense ; and to these symptoms was added headache, and some- 
times cough. On the third or fourth day after delivery, the mammae 
became flaccid. On opening the bodies, curdled milk (s^c) was found 
on the surface of the intestines, and a milky, serous fluid in the 
peritoneum. A similar fluid was found in the thorax of certain women ; 
and Avhen the lungs were divided, they discharged a milky or putrid 
lymph." 

During the latter half of the eighteenth century, violent epidemics 
appear to have occurred in most of the principal towns of Europe, and 
of these the history and details have, in many instances, been preserved. 
The lying-in hospitals of Vienna, Paris, Lyons, and London, were all in 
turn attacked, with results, as regards maternal mortality, too dreadful 
to contemplate. In the great hospital at Yienna, for example, the death- 
rate has reached as high as one in six of all the women admitted. It 
would appear, further, that the disease, Avhen once established in a 
locality, showed a tendency to return ; and, with regard to Paris, Tenon 
observes, that " it has come to prevail more and more, and to be, as it 
were, naturalized." We must not suppose, however, that the mortality 
from this cause was only observable in the statistics of lying-in hospitals, 
for the disease spread by contagion as well as by epidemic influences, 
through all classes of society ; and there can, we presume, be little 
doubt that the mortality Avas enormously increased by the obstinate 
incredulity of those who refused to admit that the disease Avas contagious. 
Still, it has ahvays been upon lying-in hospitals that the great Aveight of 
mortality has fallen ; and, although improvements in construction, and 
the greater attention Avhich is noAv paid to ventilation, cleanliness, and 
disinfection, have greatly reduced the hospital death-rate, there is no 

^ Memoires de FAcademie des Sciences. 1746. 



EPIDEMICS. 681 

doubt that much yet requires to be accomplished before perfection is 
attained, or even approached. 

The statistics of the London, Dublin, Edinburgh, and Aberdeen hos- 
pitals all show that, wherever observed, the disease was a very fatal one ; 
but if we examine into the details given of previous epidemics, we can- 
not fail to be struck with the fact that there has been a great variety in 
their nature. When we find a history of an epidemic in which the 
mortality has been comparatively trifling, and blood-letting has obviously 
been attended with a beneficial result, we may well doubt whether this 
should be called puerperal fever. But, putting aside for the moment 
such doubtful epidemics, we find that when the asthenic type of the dis- 
ease is perfectly marked from the outset, the local lesions vary at dif- 
ferent times ; and we thus observe that in some epidemics the peritoneum 
is chiefly involved, while in others the affection of the joints, and other 
distant parts, may be held to indicate the presence of uterine phlebitis 
as the special characteristic of the prevailing epidemic. Another fact 
which stands out very prominently in the history of epidemics, is the 
marked variation in the intensity of the disease, or the virulence of the 
poison, so that in one case we have a low percentage of deaths, while in 
another the patients are, as it were, struck dead by a fever which runs 
its course in a few hours. 

It is a fact, beyond all question, that the disease we are now consider- 
ing attains its maximum of intensity in hospital epidemics. It usually 
originates in the course of the second, third, or fourth day, although 
sometimes later, and cases have been recorded in which it has come on 
before delivery. It is often ushered in by a rigor, but this is far from 
being invariable ; and, indeed, it may be remarked that the violence of 
the rigor is in this case much less marked than in some instances, where 
the impending disorder is comparatively trivial. The patient is conscious, 
from the first, of a feeling of great depression, which is often accom- 
panied with headache and uneasiness at the prsecordial region. There 
has often been observed, even thus early, a haggard, anxious expression 
of countenance, as if she were in dread of an impending calamity. The 
pulse is feeble, or at least compressible, and is seldom less than 130, 
rising in many cases to 150 and upwards. Extreme rapidity is a very 
bad sign, especially if associated with a high temperature. There may 
sometimes be a rigor and a hot stage, quickly followed by free perspira- 
tion, which, supposing it to be critical, we may look upon as a favorable 
augury ; but, as the case goes on, we soon observe that the discharge 
from the skin brings no relief to the symptoms ; it continues profuse to 
the end, and a peculiar odor has sometimes been observed. Those in- 
stances in which the perspiration constitutes a peculiar feature of the 
case are not common, but were considered of sufficient importance by 
Blundell to warrant him in describing a distinct variety of puerperal 
fever, which he, from the leading symptom, called " Hidrosis," or " Hi- 
drotid Fever." 

Generally speaking, however, the skin is hot and dry, although 
towards the termination of a fatal case it becomes cold, damp, and 
clammy. The eff"ect produced on the milk and lochia is variable, and 
there are even cases in which these discharges are more than usually 



682 PUERPERAL FEVER. 

abundant. Vomiting is by no means an uncommon symptom ; but it 
does not generally come on very early, and the matter ejected is some- 
times dark in color, like coffee-grounds, and occasionally very offensive. 
Diarrhoea is, as we have already seen, an almost invariable symptom in 
the later stages of those inflammatory affections which pass into puer- 
peral fever ; but, in cases of the ordinary type, diarrhoea frequently 
comes on at a much earlier stage, when the offensive nature of the 
evacuations often indicates still further the extent to which the digestive 
functions are involved. The tongue presents at first no distinctive 
character, but, as the case rapidly advances, the deep fur — white or 
brownish, moist or dry — is a further index of the extent to which the 
normal functions are disturbed. Marked delirium is not usual, but there 
is often observed an excited condition in which the patient exhibits a 
peculiar tendency to loquacity, amounting, it may be, to slight delirium 
in awaking from sleep. 

In a very large proportion of cases, the peritoneum, or uterus, or both, 
are involved. Thus, one of the earliest symptoms, after the disease has 
been thoroughly established, is abdominal pain, which either originates 
in the hypogastric region, or, more exceptionally, in the epigastrium. 
The pain is excessively acute, so that the patient will frequently complain 
of the weight of the bedclothes ; and it is soon accompanied with more or 
less swelling, or tumefaction, — the enlargement being due, in the first 
instance, to flatulent distension, and, subsequently, to fluid effusion, 
which is poured into the cavity of the abdomen. In some cases, the pain 
is associated with enlargement of the uterus, which may be recognized 
through the abdominal walls. This has sometimes given rise to the idea, 
when the general symptoms were not carefully observed, that the pain 
was simply due to those irregular contractions of the organ which are 
commonly known as after-pains. 

As the abdominal distension increases, which often happens with ex- 
treme rapidity, the sufferings of the patient are proportionally augmented. 
She now lies on her back, breathing rapidly, sometimes with her knees 
drawn up, and exhibiting on her countenance that appearance of ghastly 
distress which is so painful to witness. The surface and extremities 
become cold ; the mechanical impediments to perfect respiration give 
something of lividity to the countenance ; and the symptoms, becoming 
otherwise more grave, indicate that the period has been reached when 
hope may be well-nigh abandoned. At this period the abdominal pain, 
tenderness, and tension often diminish; and, but for the ominous pulse 
and countenance, we might fancy that the patient was better. The diar- 
rhoea continues, the motions being passed in bed ; vomiting occurs, with- 
out any retching, of a dark or greenish matter ; and the patient may 
now breathe with greater ease. The pulse is undiminished in frequency, 
but it is otherwise changed for the worse, as is indicated by its thready 
or imperceptible character. The intellect generally remains clear to the 
end ; but in some cases low muttering delirium, subsultus tendinum, and 
other similar symptoms, come on before death ensues. 

Such symptoms are, as will be observed, almost identical with those 
which have been described as characteristic of the fatal inflammatory 
afiections previously mentioned. If we attempt to follow the description 



MORBID ANATOMY. 683 

and classification of various authors, we find that the varieties and di\4- 
sions of puerperal fever are infinite, and are, were Ave disposed still 
further to classify, susceptible of more elaborate subdivision still. For 
our present purpose, however, it may suffice to observe, that although 
we believe the symptoms above detailed to be among the more important 
of those which arise in the course of an ordinary septicaemic case, other 
varieties may exhibit themselves, in the experience of any man, which 
may differ in important particulars. But we recognize in this admission 
no reason for more elaborate classification of a subject which has already 
been classified out of all shape, and which, plastic as it is, it is difficult 
to mould into a simple, comprehensive, and comprehensible form. 

Morbid Anatomy. — The various forms into which puerperal fever may 
manifest itself involve, almost necessarily, a corresponding variety in the 
appearances produced in the different tissues which may be implicated. 
In the case of the post-partum inflammatory affections which, after a some- 
what longer course, apparently pass into puerperal septicaemia, and 
thence to a fatal result, the appearances of an ordinary local inflamma- 
tion are, as we might confidently anticipate, more distinctly revealed. 
In peritonitis, for example, the more closely the case resembles, in its 
symptoms and progress, the purely local disease, the more closely do the 
morbid consequences correspond. "When the septic infection is concen- 
trated or malignant, as in hospital epidemics, the fatal result ensues with 
such rapidity that there are really no marked post-mortem appearances. 
In ordinary cases, however, the lesions are conspicuous. In many cases 
there may be observed in the vulva, vagina, or cervix, or at the site of 
the placenta, an ulcerative action at the margin of the existing wound. 
This is called the " puerperal ulcer," and the neighboring parts will be 
found to have participated more or less in the unhealthy action. Inflam- 
mation, softenino;, and even slouo-hino; or 2;an2:rene of the mucous mem- 
brane of the womb, is often noted, the extent of the changes corresponding 
in some degree to the virulence of the morbid action. The pelvic con- 
nective tissue is very generally the seat of a diffuse inflammatory oedema, 
to the development of which the relaxed condition of the parts gives me- 
chanical encouragement. The inflammatory process has also been traced 
to the lymphatics, the veins, and the parenchyma of the uterus, and in a 
large proportion of the fatal cases the inflammation will be found to have 
spread to the peritoneum, and from that again by mere continuity of 
tissue to structures more remote. 

In some cases there is found clear pathological evidence of inflamma- 
tory action in distant organs which cannot have been transmitted thither 
by continuity. These appearances will generally be found to have refer- 
ence to symptoms manifested during life, and constitute what is usually 
called metastasis. A new interest has been given to this subject by the 
discoveries of Virchow and his followers in regard to thrombosis and em- 
bolism, and we can have little hesitation in admitting the possibility of a 
fragment of an infected and disintegrated thrombus being conveyed by 
the circulation to a point in the arterial system, where, being arrested, it 
becomes a fresh centre for violent inflammation. Billroth and Waldeyer 
refer all circumscribed metastatic inflammation to embolism, but in the 
present state of our knowledge this is certainly going too far, although 



' 684 PUERPERAL FEVER. 

we may a Imit that this theory gives us by far the most satisfactory ex- 
planation of the phenomena of metastatic inflammation in these cases, 
and more particularly of the formation of purulent deposits in distant 
organs. 

In regard to these distant abscesses, it may here be remarked that 
they have most frequently been found associated with the malignant or 
epidemic variety of the disease, of which we have many descriptions, 
chiefly from hospital experience. On this point, Boivin and Dug^s ob- 
serve that '' pus is sometimes found even in the substance of the womb, 
and generally nearer to its exterior than its interior surface. Thus, pus 
collects into distinct abscesses, from one to five inches in diameter — 
sometimes into a simple or multilocular deposit, with a greenish or 
viscous appearance ; at other times it is infiltrated into the fleshy fibres, 
imparting to them a reddish-yellow color, perceptible through the peri- 
toneum. In this latter case, tumors form — which are sometimes hard 
and projecting — upon the fundus uteri ; at other times, they are flattened, 
soft, and broad. These latter come further down towards the lateral 
regions, and often form a continuation, together with purulent infiltration 
between the laminae of the broad ligaments, with the cellular tissue of 
the pelvis and the substance of the ovarian ligaments." This has 
reference to certain secondary purulent formations which we shall have 
occasion to notice in our next chapter. There is here, also, as in the 
peritoneal form when rapidly fatal, a tendency to turbid efl'usion into the 
serous cavities. 

The most interesting, however, of all the points upon which pathological 
anatomy may be expected to throw light, are those which are connected 
with uterine phlebitis — an affection which has, as we have seen, been sup- 
posed by eminent modern writers on the subject to bear the most intimate 
relation to true puerperal fever. The primary and essential morbid 
change in this variety is inferred from the condition in which the ovarian 
and uterine veins, and their branches within the uterus, have been found. 
We do not doubt that here, as in phlegmasia dolens, erroneous inferences 
have been drawn from a mere discoloration of the lining membrane of 
the vein, associated with the presence of a clot ; but many of the appear- 
ances which have frequently been observed and described, are so un- 
equivocal, that the existence of true phlebitis must be conceded. Of this 
nature are thickening, contraction, and absorption of the tissues of the 
vein, and the presence of lymph and pus as obvious products of local 
inflammatory action. Certainly in some cases, and probably in many, 
this inflammation of the veins is associated with softening of the muscular 
tissue, or some other sign equally significant of metritis. 

In the less severe cases, it will probably be found that the inflamma- 
tory process has not extended further than the veins of the uterus itself, 
or the veins which directly communicate with it ; but, in some in- 
stances, evidence of inflammation is said to have been traced as high 
as the renal veins, or even the vena cava itself, although there is reason 
to believe that, in these latter examples, the mere presence of pus in 
the vein has sometimes been admitted as evidence of inflammation of its 
structure. 

The presence of pus within the veins, in the region of the uterus, is to 



MALIGNANT VARIETY. 685 

be accounted for chiefly by the changes which take place in the blood- 
clot, Svhich is the more inamediate result of phlebitis. Coagulation is, as 
we have seen, equally the result of py^emic action ; but we are here con- 
sidering it as the effect of, or, at all events, as associated with, true in- 
flammation of the veins. From the disintegration and decomposition of 
the blood-clot, pus is evolved, and becomes the cause of some of the 
more characteristic of the morbid appearances of uterine phlebitis. The 
circulating medium is poisoned with pus, the result of which may be 
immediate septic coagulation ; or, the poison being carried, by detached 
portions of the thrombus or otherwise, to distant localities, it there pro 
duces the secondary phenomena which are disclosed after death. In a 
large proportion of these cases, swellings are observed in the neighbor- 
hood of the joints, which, on being freely incised, give exit to pus. In 
the worst cases, pus is found within the joint itself, and the ligaments 
and cartilaginous surfaces afibrd proof of a rapidly-destructive inflamma- 
tion. If the eye has been afl"ected, evidence will there be found of in- 
flammation, of equal violence, although limited in extent. Abscess may 
also be found in the muscles or cellular tissue of the limbs ; and, in other 
cases, what has been supposed to be an abscess has turned out, on ex- 
amination, to be an eff"usion of sero-sanguineous fluid. The brain is 
rarely aff"ected ; but, within the cavity of the chest, clear evidence has 
often been observed of that metastasis of inflammation to which allusion 
has already been made, sometimes Avithin the lungs — which have been 
found condensed, of a dull red color, and infiltrated with purulent matter 
— while, at other times, the violence of the disease seems to have ex- 
pended itself mainly on the pleura. The heart is often enlarged and 
softened ; and, within the pericardium, lymph and serum may, with the 
usual alterations in the membrane itself, aftbrd conclusive proof that in- 
flammation has been present here also. The various portions of the 
intestinal canal, from the stomach to the rectum, have, in exceptional 
instances, been found to have been severely afl"ected, usually by a simple 
extension of the inflammatory process from the contiguous position of the 
peritoneum. Ulceration and perforation of the stomach have been noted 
in some of those cases. The spleen and liver have also been found to 
be extensively disorganized, and their tissues the seat of single or 
multiple abscesses. In the greater number of the cases which were 
examined by Dr. Hulme, he found the omentum inflamed, and frequently 
black and gangrenous. In no small proportion of fatal cases, the kid- 
neys have been found to present evidence of similar disorganization, 
obviously the result of violent inflammation : generally speaking," one 
kidney only is afiected. 

In the malignant variety of the fever, the following indications, in 
addition to those which have been already detailed, are mentioned by Dr. 
Copland, in his " Dictionary of Practical Medicine." In several cases, 
in which blood-letting had been practised, he observed, that " on every 
occasion I was struck by the peculiar faint odor, and very dark hue of 
the blood ; by the very soft state of the clot when the blood did separate 
into crassamentum and serum ; by the appearance which occasionally 
presented itself, of a mass exactly resembling, in color and consistence, a 
common jelly, the coloring matter covering the bottom of the vessel in 



686 PUERPERAL FEVER. 

the form of a precipitate ; and by, in some instances, a separation only 
of serum, the large, loose, gelatinous crassamentum consisting chiefly of 
this jelly-like matter, the lowest stratum of which contained the black or 
dark-brown precipitate of coloring matter. These appearances of the 
blood were presented in several cases in the hospital, in 1823 and three 
or four subsequent years, in which cases blood had been taken before 1 
saw the patients. It may here be remarked, that I have seen many 
cases of this form of the disease, in which leeches had been applied to 
the abdomen; but in nearly all, and especially in those which occurred 
in the hospital, the blood which flowed from the bites did not coagulate ; 
and great difficulty, almost amounting to an impossibility, of arresting 
the bleeding from them was generally observed, owing both to the state 
of this fluid, and to the impaired vital cohesion of the tissues, character- 
izing the advanced stage of the malignant form of this domestic pesti- 
lence." This condition of the blood, which has frequently been remarked, 
points very significantly to the operation of some powerful morbid poison. 
In the cases which prove most rapidly fatal, nothing may, indeed, be re- 
vealed on examination, beyond this peculiar condition of the blood, and, 
it may be, a little turbid serum in the peritoneum and the other serous 
cavities. 

The pathological appearances, then, are no reliable indication of the 
virulence of the attack, as has also been frequently observed in the case 
of other febrile diseases which prove rapidly fatal. Generally speaking, 
however, in very severe cases, the extent of the local lesions is commen- 
surate with the severity of the attack ; and, although we may meet with 
cases ultimately fatal, in which the mitro-peritoneal symptoms are 
moderate in degree, a careful examination will usually disclose irre- 
fragable evidence of violent local inflammation. While, therefore, the 
appearances are often such as to indicate a degree of malignancy and 
rapid action, which can only be explained on the hypothesis of puerperal 
fever, we are aware of no mode of disclosure by which morbid anatomy 
can reveal to us, with even an approach to certainty, how we may dis- 
tinguish between the various types of the disease. The post-mortem 
appearances in the sporadic variety are certainly much less formidable 
than in the epidemic form ; and, indeed, it is evident that the descrip- 
tion, both of symptoms and of morbid appearances, which we read in 
man}^ admirable works, is founded almost entirely upon an experience of 
hospital epidemics ; whereas it should be clearly understood that the 
disease in sporadic cases, or even when communicated by contagion in 
private practice, is, as a rule, much less disastrous in its results than the 
once dreadful, and still formidable scourge of lying-in hospitals. 

Another point which we have already alluded to, in reference to the 
symptoms, is also borne out by a careful analysis of recorded morbid 
phenomena. This is the tendency in the disease to change its type or 
form, as evidenced by the tissues which, in successive epidemics, or even 
at short intervals during the same epidemic visitation, are mainly 
affected. It were easy to multiply illustrations of this, but we shall, in 
the mean time, content ourselves with the following example, from the 
experience of M. Tonnelle. " Softening of the uterus," he states, 
" after showing itself frequently in the first half of the year 1822, and 



TREATMENT. 687 

particularly about January, disappeared entirely in the months of July 
and August, which were characterized, in a remarkable manner, by the 
frequency of inflammation of the veins. Afterwards, it began to rage 
anew with great violence in September and October, and again disap- 
peared in the last two months, during which term the mortality was 
inconsiderable." 

Treatment. — The treatment of puerperal fever varies according to the 
class to Avhich each case belongs : nothing can well be imagined more 
absurd, and nothing, in fact, has been more disastrous in its results, than 
to manage all cases of puerperal fever upon one and the same principle. 
One feature, indeed, is common to nearly all the cases, and consists in 
the contagious nature of the disease. This is the leading idea, which, 
more than anything else, w^e would again impress upon the student with 
all the emphasis at our command. Whether the case be one of peritoni- 
tis, metritis, or malignant puerperal fever, the risk of contagion must 
always be borne in mind ; and although we must admit that the danger 
is much less in, for example, simple peritonitis, we can never be sure that 
it is absent, and therefore we should treat every case, without exception, 
as if its contagious nature were already demonstrated. 

A further reference to the history of various epidemics shows, Avith 
remarkable clearness, that methods of treatment which have been found 
useful at one time have proved the reverse of beneficial at another. Dr. 
Gordon, who, in 1789, when the disease appeared in Aberdeen, saw a 
large number of cases, w^rote, several years afterwards, a most excellent 
treatise on the subject, in which he drew attention, with much force of 
argument and illustration, to a new and successful method of practice, by 
means of the bold and early use of the lancet, — taking twenty or twenty- 
four ounces at once, and, if necessary, ten more soon afterwards. 
" When I took away," he says, " only ten or twelve ounces of blood 
from my patient, she alivays died ; but when I had the courage to take 
away twenty or twenty-four ounces at one bleeding, in the beginning of 
the disease (^. c, within six or eight hours after the attack) tlie patient 
never failed to recover. After the bleeding, it was my practice to bring 
on a diarrhoea, which, when excited, I found necessary to continue 
through the whole course of the disease, till it was entirely conquered." 
Nothing, we would say, were we reading of a new and unknown disease, 
can be more simple than this ; nothing more clear than the indications of 
practice. In an epidemic which occurred in Leeds early in the present 
century, the treatment of Dr. Gordon was energetically adopted by Mr. 
Hey ; and although, prior to this, every case that had come within his 
knowledge died, no soonei' did he purge his patients and bleed them 
early, to the extent of thirty, forty, and even fifty ounces, than they 
recovered, in the proportion of thirty cases out of thirty-three. Such 
facts, which were further corroborated by Armstrong, Mackintosh, and 
others, were held to be so significant, that for many years the treatment 
of epidemic and contagious puerperal diseases was, simply, heroic blood- 
letting. 

About 1829, a remarkable essay was published by Gooch on what he 
terms " The Peritoneal Fevers of Lying-in Women," which effectually 
staggered the belief of those who had clung most persistently to the bold 



688 PUERPERAL FEVER. 

measures of Gordon. It would seem that, before this, doubt, founded 
upon unsuccessful results in treatment, had sprung up in the minds of 
many ; but, till Gooch wrote, no one had had the courage to controvert 
ideas so generally entertained. One of the first points to which he calls 
his readers' attention, and which he states with great force, is the marked 
distinction which subsists between various epidemics, and the result of 
their treatment at the hands of different observers, who imagined that 
they were all treating the same disease. He makes it quite obvious that 
the disease of which William Hunter says, " of those attacked by this 
disease, treat them in what manner you will, at least three out of four 
will die," cannot be, in all respects, the same as Dr. Butter treated in 
Derbyshire, " with ten grains of rhubarb and ten grains of cordial confec- 
tion every day," without a single fatal result. Nor can it be possible 
that the fatal scourge of the London and Paris hospitals can be the same 
as that observed by Richter of Gottingen, of which he observes, " I have 
often seen the childbed fever, and always treated it successfully." 
Gooch began his practice with a decided prejudice in favor of blood- 
letting, and his results seem to have been so far satisfactory, when he 
saw the patients early ; but, when several days had been allowed to 
elapse, the issue was almost uniformly fatal. As his experience in- 
creased, he fully recognized the fact, that a blind and slavish adherence 
to the lancet sometimes inflicted irreparable injury upon the patient. 

In 1823, Dr. Copland was appointed consulting physician to Queen 
Charlotte's Hospital, and the result of his experience is given by Dr. 
Ferguson. " The disease was malignant, and often ran its fatal course 
in twenty-four hours from the first appearance of the symptoms. . . . 
The treatment ultimately adopted by Dr. Copland for this malady was 
boldly stimulant. Immediately upon the appearance of the symptoms, 
a bolus containing from eight to sixteen grains of camphor, from ten to 
twenty grains of calomel, and from one to three of opium was given, 
and repeated in four, five, or six hours. The dose of camphor was 
very rarely less, and but seldom above that named, and the interval 
between the two doses sometimes only three hours, but never longer 
than six hours. The dose of opium in the second and subsequent 
boluses was regulated according to the effect of the first. Soon after 
the second bolus was administered, about half an ounce of spirits of 
turpentine and an equal quantity of castor oil was given, on the surface 
of some aromatic water ; and, if these did not operate fully on the bowels 
within three hours, the same medicines in double and treble quantity 
w^ere administered in enemata. The bolus just mentioned was still 
continued at the same intervals, or after five or six hours from the 
exhibition of the second or preceding one. Very soon afterwards, and 
generally subsequent to the administration of the turpentine draught 
and enema, a large piece of flannel folded several times, and sufficient 
thus to cover the whole abdomen, was directed to be wrung as dry as 
possible out of very hot water, to be instantly freely sprinkled with 
spirits of turpentine, and applied over the abdomen, to be closely 
covered by wash leather or a dry cloth, and to be kept thus applied for 
some time, or renewed until erubescence of the surface of the abdomen 
was produced. The success of the above treatment in the malignant 



TREATMENT. 689 

form I found to be almost complete, for scarcely a case terminated fatally 
in which it was early resorted to." 

It is quite clear that the stimulating treatment detailed in the above 
extract, and which was attended with results so satisfactory, must have 
been directed against a fever of a different type from that which was 
encountered by Gordon and Hey. The more, indeed, do we study the 
history of puerperal fever, the more prominently does the fact stand 
out that the type of the disease has varied much during the last hundred 
years ; and that while, in one epidemic, the sthenic or inflammatory 
nature of the symptoms has been such as to warrant the boldest anti- 
phlogistic treatment, in another, the asthenic type has prevailed from 
the first, when stimulant treatment has alone been attended with success. 
We shall not here enter upon the question, whether or not there has 
been, as some have alleged, a general change in the type of all diseases 
from the sthenic to the asthenic form ; but, admitting the force of many 
facts which have been advanced in support of this assertion, we confess 
to having entertained all along a strong impression that the idea has led 
to an all but invariable discontinuance of sfeneral blood-lettino; as a fea- 
ture of modern practice, which is an exaggeration, and, as such, to some 
extent, an error. It is quite clear, however, that, during the last fifty 
years, the type of puerperal fever has been usually, although not invari- 
ably, asthenic or adynamic. 

AH this leads directly to the practical conclusion that, although the 
nature of the treatment to be adopted should depend upon the type 
under which the disorder presents itself, and also upon the stage at 
which the case is brought under the notice of the physician, that type is, 
in the experience of all modern practitioners, mainly asthenic. There 
is no single plan of treatment applicable alike to all cases. Indiscrimi- 
nate blood-letting is sure to lead to disaster, and invariable stimulation 
is not free from risk. It is the first duty, therefore, of the judicious 
practitioner to determine the nature of the individual case, and the 
special treatment proper to it. The cases to which blood-letting is 
most applicable are undoubtedly those in which the earliest symptoms 
indicate acute inflammation of the peritoneum, of the uterus, or, more 
probably still, of both. When a patient, therefore, of robust constitu- 
tion, complains, after a rigor, of acute hypogastric pain, which is 
accompanied by a rapid, incompressible pulse, throbbing temples, and 
suffused countenance, we should not hesitate to apply from ten to twenty 
leeches over the surface of the abdomen. Few persons nowadays 
would be bold enough to bleed from the arm, but it by no means 
follows that there are no cases in which this would not be the more 
judicious treatment. If the thing is to be done at all, it must be done 
boldly ; and, above all, it must be done early, for, if the patient has 
passed the acute stage, to bleed her is probably to hasten her doom. 
It is to be remembered, however, that cases do occur in which the 
symptoms are such as to bafile even the most experienced observer ; 
and in such instances it has been suggested that the bleeding should be 
more tentative in its nature, the effect of the flow being carefully noted, 
and only continued if the pulse and other indications show that it is 
being well borne. 
44 



690 PUERPERAL FEVER. 

It does not, in the least, matter what names we give to those acute 
aifections upon which blood-letting has been found to produce so decidedly 
beneficial an effect. For all practical purposes, it is sufficient carefully 
to distinguish between them and the purely septic cases, in which blood- 
letting is inadvisable, unless inflammation should arise as a complication, 
and at an early stage. A rapid, compressible pulse, distended abdomen, 
diarrhoea, and the characteristic appearance in the countenance of ghastly 
distress, are among the more important of the signs which indicate that 
depletion must not be ventured upon. 

The same simple rule must be our guide as to the administration of 
purgatives. Free purgation is generally proper, in the cases to which 
venesection is applicable ; and it is well known that in simple peritonitis, 
constipation is an almost invariable symptom. Our object is to eliminate 
the septic material through the channel of the alimentary canal. The 
extent to which purgation is to be carried, and the class of medicine to 
be selected, must be determined, in each case, according to the judgment 
of the medical attendant ; but it may be well for him to remember that, 
in some fatal cases, the morbid appearances have been such as to suggest 
the probability of an irritant action from violent drastics having had 
some share in the result. It is better, therefore, when the bowels do not 
respond to a sufficient dose, rather to supplement that by an enema, than 
to run the risk of further irritation. In the later stages of the ordinary 
disease or in the malignant variety, strong purgatives are contra-indicated, 
not only because diarrhoea is a common symptom towards the end, but 
because there is no hope of a beneficial derivative action from the bowels. 
To such a case, the milder laxatives, or enemata containing turpentine, 
are appropriate. 

[The disease to which the author evidently alludes, in speaking of 
blood-letting, is peritonitis, to which the term puerperal may be appro- 
priately prefixed. We have seen a number of cases of this affection, and 
have resorted to blood-letting occasionally for its relief. We know of no 
remedy the use of which is followed by more brilliant results, but to be 
of any service it must be employed at the outset of the disease, certainly 
within the first twenty-four hours after its commencement. The patient 
should be bled when sitting up in bed, and the flow should not be checked 
till syncope is about to occur. To be useful, venesection must be em- 
ployed boldly. We have seen it terminate the disease at once. 

There are few American practitioners, however, who follow either 
general or local depletion by the use of purgatives. These are very 
universally condemned in this country as dangerous remedies in this dis- 
ease. They excite peristaltic action of the bowels, and increase rather 
than relieve the irritation and inflammation. 

The depletion should be followed by the use of veratrum viride and 
opium. Of the former enough should be given to keep the pulse 
thoroughly under control. It should be kept at 75 or 80 per minute. 
Opium relieves pain, quiets emotional disturbance, allays nervous irrita- 
bility, and arrests the peristaltic movements of the bowels. It has to be 
given boldly and in large quantities, because in this disease there is a 
remarkable tolerance of its effects. Professor Alonzo Clark, with whom 
this plan of treatment originated, says that a woman " who was unaccus- 



PURGATIVES. 691 

tomed to the use of opium in health, and who was not intemperate, took 
the first twentv-six hours, of opium and sulphate of morphia, a quantity 
equivalent to 106 grains of opium ; in the second twenty-four hours she 
took 172 grains; on the third day, 236 grains ; on the fourth day, 120 
grains; on the fifth day, 51 grains; on the sixth day, 22 grains ; and on 
the seventh, 8 grains." It is therefore apparent that we are to be 
guided by the etfect produced rather than by the quantity of medicine 
administered. My own rule is to give enough of some fluid preparation 
of opium to bring the respirations down to 12 per minute. The proba- 
bilities are that they will fall to 10 or even to 8, w^hich need occasion no 
alarm if the medicine has been carefully given. To produce this impres- 
sion it is safe to commence with doses of one-third or one-half of a grain 
of morphia in solution, given every hour, and continued until the desired 
effect is produced. If it fails in this, the dose must be increased until 
the woman is semi-narcotized. The eifect must be produced, no matter 
what quantity of opium is needed to do it. If vomiting interferes with 
the administration of the remedy by the stomach, it may be given by 
hypodermic injection. 

The opiate often has to be continued for many days. The tolerance 
of the patient is the best guide to follow in deciding when to diminish the 
quantity or to stop its use. As the disease improves, the tolerance 
diminishes. Patients are often injured by stopping the opium too soon. 
This fact cannot be too strongly impressed upon the mind of the young 
practitioner. 

The local treatment of peritonitis is important. Turpentine stupes 
applied to the abdomen, and kept on as long as the patient will bear 
them, are useful as counter-irritants, while, as Prof. Barker says, enough 
of the remedy is probably absorbed to produce some constitutional efi"ect. 
This is shown in the restoration of the suspended lochial discharge, the 
diminution of the tympany, and the stimulation of the patient. When 
the turpentine is removed, the abdomen should be covered with soft 
cloths, wet with warm water, to which laudanum may or may not be 
added, according to circumstances. The whole should be surrounded 
with oiled silk. We have seen blisters applied in the early stage of the 
disease, but at this time they are not only useless, but are actually inju- 
rious. During the second stage, after the acute symptoms have disap- 
peared, a blister is useful in the treatment of inflammatory indurations 
w^iich result from the disease. Under these circumstances it not only 
subdues the remaining inflammation, but it materially assists in efl'ecting 
the resolution and absorption of the inflammatory formations in the peri- 
toneal cavity. 

If the symptoms of purulent infection should supervene, in consequence 
of an attack of general peritonitis, the patient must be treated as in 
other cases of pyoemia. — P.] 

In the worst forms of the disease, and especially in hospital epidemics, 
the power of medicine and the skill of the practitioner are alike set at 
defiance ; but, however desperate the symptoms, and apparently hopeless 
the prognosis, we must persevere so long as life lasts. Between simple 
puerperal peritonitis and the malignant fever — 'which is as deadly as the 
plague — infinite varieties may be observed ; but the management of all 



692 PUERPERAL FEVER. 

will be more successful if we proceed upon general principles, rather than 
minute and special distinctions. We shall, therefore, content ourselves 
by mentioning, in addition to the means already detailed, the various 
remedies which have been found useful by the most experienced and able 
of those who have written on the subject. 

M. Doulcet, in the course of a severe epidemic at the Hotel Dieu, 
thought of using emetics at an early stage of the disease, and the results, 
as detailed by him, were eminently satisfactory. Subsequent experience, 
however, has not realized, in the hands of others, the hopes which 
M. Doulcet's statements seemed to encourage. The emetic employed 
was ipecacuanha, and it was repeated daily until the symptoms were 
subdued, — a potion being administered in the interval, composed of oil 
of almonds, syrup of marsh mallow, and Kermes mineral. At one time, 
calomel was given very freely in those cases, and, on the whole, as it 
would appear, with benefit. On this point Gooch observes, " I have 
never given it systematically in a number of cases, but what experience I 
have is in its favor. In the Westminster Lying-in Hospital, where ten 
or twenty grains of calomel used to be given every day, with purgatives, 
the gums sometimes were affected, and these patients invariably recov- 
ered." The fact of all those recovering where the gums were affected 
may, however, be otherwise explained, on the supposition that if they 
live long enough for mercury to produce its constitutional effect, the 
urgent danger of the case has necessarily, in some measure, passed. It 
will generally be found advantageous to combine opium with the mercury, 
but in this respect, much will depend upon the stage which the disease 
has reached. Spirits of turpentine has been very highly recommended in 
the treatment of puerperal fever, and in doses of one drachm, as recom- 
mended by Copeman,^ we have seen striking and satisfactory results. 
Flatulent distension of the bowels is, moreover, so frequent a complica- 
tion, that we would naturally anticipate some benefit from this drug, 
although, perhaps, in this sense, it would be more correctly described as 
a palliative. In point of fact, there is nothing of the nature of a specific 
remedy which we are warranted in recommending with any confidence, 
but it is proper that attention should be called to the sulphites and sul- 
phurous acid, both of which have been strongly supported by some 
recent German writers ; and it is well to remember that, if the sulphites 
are freely employed, a purgative action, which we are desirous on other 
grounds of producing, will be induced. The cold water treatment, which 
has so undoubted an effect in reducing temperature, has received the sup- 
port of Schroeder, but it is more than doubtful whether we would be 
justified in anticipating from this any more reliable effects than from the 
specific remedies hitherto suggested. 

Blisters to the abdomen have been thoroughly tried, but without any 
very satisfactory results. Among modern authorities. Dr. Churchill 
seems, however, to have retained some belief in their efficacy, and says 
that, from the cases he has seen, he is " inclined to think blistering use- 
ful, and it affords an opportunity of applying mercurial ointment to a 
highly-absorbent surface." Iodine has also been suggested, but the ex- 

1 Records of Obstetric Consultative Practice. London, 1856. 



STIMULATION". 693 

ternal applications which find most favor are either warm poultices or 
turpentine fomentations. 

The asthenic character which has been so generally observed in the 
more recent epidemics has led many, whose experience has been confined 
to cases of this tj^pe, to discard all treatment in favor of a stimulant and 
tonic regimen from the first. Dr. John Clarke gave bark in powder and 
decoction, with opium and wine. M. Beau found great benefit in the 
use of quinine in doses of fifteen to thirty grains in the day. Certainly, 
the results of free stimulation have been such as to warrant us in perse- 
vering, while life lingers, in the use of this, which is perhaps the most 
valuable class of remedies at our command. 

It has lately been proved by Mr. Spencer Wells that, after ovariotomy, 
benefit is derived by boldly tapping and withdrawing large quantities of 
turbid serum, in cases in which extreme efi"usion had come on in con- 
nection with other symptoms of septicaemia. It remains to be determined 
by the experience of the future, whether, by puncture from the vagina 
or in the abdominal walls, the withdrawal of similar effusions may, in 
puerperal fev^er, be attended with equally favorable results. 

The topical treatment of the most probable centres of septic infection 
must never be lost sight of. It is to be feared that the dread which 
attaches to this disease renders practitioners sometimes culpably timid 
in regard to the manipulation of the genital organs, and so duties are 
left absolutely to the nurse which ought at least to have our careful 
supervision. If, in any case, fetor or any other abnormal symptom 
should arise in connection Avith the discharges,, antiseptic injections are 
indicated ; and, if necessary, carbolic dressings should be applied to the 
lacerations, and even weak solutions of carbolic acid injected into the 
uterus. This, with the strictest attention to cleanliness, will go far to 
check or modify the progress of the disease. 

The question of prophylactic treatment, which naturally suggests 
itself here, is second in importance to no point relative to our subject. 
The rules of lying-in institutions are generally framed with the view of 
prohibiting students who are engaged in the dissecting-room from the 
practice of midwifery, or, at least, point to the strictest precautions 
being observed. The danger, however, is much greater from those Avho 
are engaged as dressers in hospitals where there is erysipelas or hos- 
pital gangrene, or from those who have been engaged in post-mortem 
examinations of dangerous cases of this class. Improved ventilation has 
proved in hospitals an invaluable check on the ravages of the epidemic 
disease ; and there is good reason to believe that, in some instances, 
neglect of proper drainage has led to an aggravation of the type. The 
case of the General Lying-in Hospital, which was built on the marshy 
land by the Thames, affords an illustration of this, as after proper 
drainage the mortality in that institution diminished in the most remark- 
able manner. Where there is the slightest reason to suspect the possi- 
bility of any zymotic influence, chlorine, Condy's fluid, or carboUc acid, 
should be freely employed, as there cannot be the slightest doubt that 
these agents tend to neutralize this or any other morbid poison. Large 
lying-in hospitals, as at present constructed, must be unhesitatingly con- 
demned; for great as are the educational advantages attached to such 



694 PUERPERAL FEVER. 

institutions, the cost in human life is too fearful to contemplate. The 
smaller establishments are more easily managed, and of late years show 
a rate of mortality which is, as compared with former experience, highly 
satisfactory. Still, much in this particular direction requires to be done 
before hospitals are freed from this one special danger, and it is more 
than probable, as we conceive, that this may ultimately be achieved by 
the cottage hospital plan, the great objection to which is, unfortunately, 
especially in large towns, its cost. 

It is impossible to exaggerate the importance, in its bearing upon 
prophylaxis, of the strictest attention to cleanliness on the part of the 
practitioner, who in an ordinary case should wash his hands not only 
after but before each examination. Such a precaution would no doubt 
be scrupulously observed had he just come from a case of scarlatina or 
erysipelas, or from a post-mortem examination ; but, the more completely 
the doctrine of septic infection is established, the more clearly does it 
appear that the great majority of cases of puerperal fever are pre- 
ventable, and, if so, we may be sure that to act, in every case, as if we 
had special reason to fear that we might propagate the disease, is the 
surest way to reduce the risks to a minimum. For ordinary practice, 
thorough cleansing with hot water and soap will suffice, and the nail- 
brush should also be used, as below and at the root of the nails are the 
situations in which septic matters are most likely to be retained. The 
precautions necessary, where we have any special cause for alarm, con- 
sist in a still stricter attention to cleansing the hands, and here, in 
addition to soap and water, Condy's fluid or carbolic acid should be 
employed. We must not, however, lose sight of the fact that the finger 
of the accoucheur is not the only possible conductor of the poison. Un- 
less the nurse directly imports the poison, the fact of her attention being 
confined to one case at a time renders her less likely to infect a patient 
than a general practitioner, who, in the course of a single day, supposing 
his obstetric practice to be quite free from fever, may have visited several 
cases of scarlatina, dressed a Avounded limb aifected with phlegmonous 
erysipelas, and performed a post-mortem examination. But, on the 
other hand, the nurse in the course of her special duties comes directly 
in contact with the discharges, so that there is no point of greater im- 
portance in the education of these women than the necessity of inculcat- 
ing strict cleanliness in their own persons as well as in that of their 
patient. A weak solution of carbolic acid may be habitually employed. 
-Again, the poison may very readily be conveyed by the dress, so that 
it should be, changed where we have previously been in attendance upon 
a suspicious case. And, in like manner, the linen, napkins, syringes, 
catheters, and so forth, are possible vehicles of conveyance ; but this, 
for obvious reasons, is more likely to take place in hospital than in pri- 
vate practice. 

It has frequently happened that no cleansing, or disinfection, or change 
of dress, has had any effect in checking a series of fatal cases in the 
practice of the same person, so that no alternative remains but to with- 
draw absolutely from practice for six weeks or more. Does this not 
show that there are other modes of communication ? If we are right in 
supposing that transmission, even of a septic poison, is possible through 



i 



PELVI-PERITONITIS. 695 

the medium of the atmosphere, may we not assume that, in cases of great 
virulence or concentration of the poison, the system of the accoucheur 
may become impregnated with the poison, and that, although harmless to 
him, it may again be given off by the lungs or by the skin? It is true 
that disease germs have never been seen or traced through the air ; but 
practice founded on this belief has, in the hands of Lister and his pupils, 
been attended with brilliant results. Is it too much to hope that one 
day, by a process of antiseptic delivery, the fearful danger of this poison 
may, even in hospital practice, be reduced within narrow bounds, to the 
benefit of humanity, and the lasting credit of modern science ? 



CHAPTEE XLY. 

PELVI-PERITOXITIS: SUDDEX DEATH IX PUERPERAL PERIOD: 

AX.ESTHESIA. 

Pelyi-Peritoxitis. — Inflammation of the Uterine Appendages. — '■^Fulness," 
^'Hardness," and " 7>/mor." — Pelvic Cellulitis: Anatomy of the Pelvic 
Cellular Tissue. — Bernutz on Pelvi-peritonitis. — Diagnosis of Pelvic Cel- 
lulitis and Pelvi-peritonitis. — Engorgement of the Uterus. — Detection of Pus : 
Fluctuation. — Treatment: Alleviation of Pain: Application of Leeches., 
Poultices., Fomentations, S^-c: Methods of Promoting Absorption,- Mercury; 
Iodine ; Counter-Irritation : 7'he Operative Treatment of Abscess. — Peri- 
uterine Hoematocele. — SuDDEX Death ix Puerperal Period: Embolism 
of Pulmonary Artery — Arterial Embolism — Entrance of Air into Veins. — 
AxiESTHESiA: Vainous Ancesthetic Agents: Effects of Chloroform on the 
Blood, and on the Progress of Labor: Disadvantages of Chloroform: 
Modern Practice. 

Ix addition to the diseases which have been grouped together in the 
two preceding chapters, under the common designation of puerperal 
fever, there are other affections, chronic for the most part in their nature, 
which require some notice at our hands. These are by no means neces- 
sarily associated with the puerperal state, although about a half of all 
cases have their origin in inflammatory processes which arise, more or 
less distinctly, from the condition under which women remain for a certain 
period after delivery. The connection between the disorders which we 
are about to describe and puerperal fever is, in some cases, direct and 
unmistakable ; but, in the great majority of instances, the disease, 
although inflammatory in its nature, has no such intimate relation to 
puerperal fever as to admit of its being placed in the same category. For 
these and other reasons, it is thought better to consider the group of 
affections to which we have referred as separate from, although associated 
with, those previously described. 



696 PELVI-PERITONITIS. 

In most systematic works, even by those whose merit is universally 
recognized, these affections are dismissed with a brief notice, and 
under a great variety of names. The first difficulty, therefore, which 
we encounter, is in the matter of nomenclature — Pelvi-peritonitis, pelvic 
cellulitis, sub-peritoneal inflammation, peri- uterine phlegm.on, perime- 
tritis, parametritis, and inflammation of the uterine appendages, are 
only a few of the many designations under which this group of affections 
have been described. They may be most usefully considered together, 
for purposes of analysis and such description as is here possible. A very 
brief preliminary definition of the various terms above employed is, how- 
ever, essential. 

What was originally described by M. Nonat sls peri-uterine phlegmon, 
is better known to Eno;lish readers under the more familiar desiscnation 
of pelvic cellulitis, with which we may assume it to be almost synony- 
mous. The idea involved is an inflammatory affection, tending to the 
formation of abscess, which has its seat in the cellular tissue between the 
uterus and peritoneum, or in some other part of the same tissue within 
the pelvis. Both expressions are unfortunate, and involve a fundamental 
error. Suh-peritoneal inflammation is another synonym equally objec- 
tionable. That inflammation of the uterine appendages is very com- 
monly associated with the class of affections which we shall describe is 
universally admitted ; but if used as a comprehensive designation, as 
Churchill has employed it, it may be supposed — and, if so, very erro- 
neously — to be confined to these tissues. 

Dr. Matthews Duncan, who has treated the subject in his well-known 
work at considerable length, and with his usua? ability, adopts the words 
parametritis and perimetritis, borrowing the idea of this nomenclature, 
as he tells us, from Virchow, who, taking example from the heart and 
other organs, proposes to use peri to signify inflammation of serous mem- 
brane, and para to imply inflammation of cellular or connective tissue. 
" Perimetritis, then," he adds, "will strictly imply inflammation of the 
uterine peritoneum. Parametritis will imply inflammation of the cellular 
tissue in connection with the uterus. Similar terms may be found for 
the Fallopian tubes, perisalpingitis and parasalpingitis, and likewise for 
the ovaries. But I shall seldom have occasion to resort to them. In 
the present imperfect state of our diagnostic resources, it would be mere 
pedantry to do so frequently. There are only a few cases in which we 
can assert, during life at least, that the pelvic peritonitis is perisalpingitis, 
or perioophoritis, or that the pelvic cellulitis is parametritis, parasalpingitis, 
or paraoophoritis. To hide our ignorance on this point, it would be con- 
venient if we had a rough word expressing the internal genital organs to 
which to prefix the adverbs 'peri' and 'para.' But we have not such a 
w^ord, and I shall, therefore, in accordance with old custom, give the 
uterus the precedence, and use terms compounded of it, as perimetritis, 
parametritis, &c., without always implying, by such use, a meaning 
exclusively and properly uterine, but implicating also the tubes and 
ovaries. I shall, indeed, use the words perimetric inflammation and 
perimetritis, "parametric inflammation and parametritis, with a still 
wider meaning, implying inflammations which directly owe their origin 
to disease or injury of the uterus, tubes, or ovaries. For example, a 



NOMENCLATURE. 697 

lumbar abscess, or an iliac abscess, may be perimetric or parametric in 
origin, although lumbar or iliac in mere situation." 

Pehi-peritonitis^ again, is the name to which a preference is given by 
Bernutz, and which is used by him in a sense precisely similar to that 
which Dr. Duncan has attached to his term "Perimetritis." There is 
very little in a mere name after all ; but, if we were to select the one 
which is least likely to lead to misapprehension, we would be inclined to 
select pelvi-peritonitis, as indicating a limited peritoneal inflammation, 
involving that portion of the membrane which invests the uterus, or 
other generative organs, and often causing adhesive matting together of 
various parts, and the formation of tumors, which may be discovered 
both from the brim of the pelvis and from the vagina. 

From the results which have been disclosed by post-mortem examina- 
tions, it is certain that the uterine appendages are not unfrequently the 
seat of inflammation, varying in degree and in extent ; the action in 
some instances being confined to the peritoneal coat, and in others 
extending more deeply, so as to involve the entire thickness of the 
Fallopian tube on the side aff"ected. If the ovary is the seat of the 
disease, the result may, in like manner, be displayed, either on the 
surface of the organ, or, — should the action have reached more deeply, 
or have originated there, — the stroma may be found extensiv^ely dis- 
organized, and occupied with abscesses varying in size. Such serious 
disorganization may at any time result from an extension of the de- 
structive inflammation so characteristic of puerperal peritonitis ; but, 
in the cases now under consideration, the symptoms are generally more 
chronic from the first, and are often looked upon, in reference to other 
coexisting phenomena, as merely secondary. It can be no easy matter, 
therefore, to determine where the disease has had its origin. The 
symptoms of inflammation of the uterine appendages are almost always 
very obscure. When the pain is circumscribed by limited peritoneal 
inflammation, its site in the iliac fossa, or lateral region of the hypo- 
gaster, may be held to indicate a probability that the structures in 
question are aflected ; but there are no reliable means for determining 
whether the morbid action is limited to the peritoneum and subjacent 
tissue, or extends further, so as to involve the deep-seated structures of 
the tube, or ovary. 

The diagnosis of these afl'ections depends, in a great measure, upon 
the results of abdominal palpation and vaginal examination ; and, from 
the many fallacies which may spring in the course of such an investiga- 
tion, it may be added, that upon the special experience of the examiner 
the accuracy of any opinion which may be formed will mainly depend. 
Dr. Matthews Duncan directs attention, at considerable length, and with 
much propriety, to the loose manner in which the expressions, "fulness," 
"hardness," and "tumor," are employed in the narratives which we 
read of such cases ; and it is quite clear, although the words themselves 
are sufficiently explicit and significant, that much confusion arises from 
this source, especially, perhaps, in confounding tumor with mere hardness. 
The same remark applies to any investigation which may be made from 
the vagina; and it is, in every case, of the highest importance that we 
should determine if any connection exists between an enlargement ob- 



698 PELVI-PERITONITIS. 

servable from above and one which is made out from below. In the case 
of a solid tumor, free from serious adhesions, this is very readily recog- 
nized by such method of investigation — the impulse communicated from 
one direction being readily transmitted to the other. If it be a cyst or 
abscess, fluctuation is thus sometimes distinguished, without any difficulty, 
between the two hands, which are simultaneously employed in the exami- 
nation. But, in the case of mere diff"used fulness, or hardness, or a 
tumor which is bound down by adhesions, the difficulty of diagnosis is 
increased, to an extent which is only fully recognized by those who have 
devoted most attention to such matters. 

Pelvic cellulitis, peri-uterine phlegmon, or parametritis, — accepting 
those expressions as synonymous, — indicates, as already stated, an in- 
flammation of the sub-peritoneal cellular tissue, possibly radiating thence, 
and always involving a tendency to the formation of abscess. Until 
within a comparatively recent period, every mysterious tumor or enlarge- 
ment following delivery, was, without much hesitation, referred to this 
category. Recent investigation seems, however, to assign to it a much 
less important position. To no one is modern science more indebted, in 
reference to this subject, than to M. Bernutz ; but there can be little 
doubt that that experienced and able observer undertook to prove too 
much, when he thrust aside pelvic cellulitis,— merely admitting the possi- 
bility of its existence, — to make room for his own idea of pelvi-peritonitis. 
It is a dangerous thing to prove too much, inasmuch as anything ap- 
proaching to exaggeration is apt to attach discredit, even to investigations 
which are otherwise of the highest importance. But, freed from this 
blemish, no impartial critic can deny that M. Bernutz has rendered to 
this particular department of science the most eminent service, in boldly 
exposing the fallacies which attach to the familiar idea of pelvic cellu- 
litis. 

The "slightest dissection," says the writer referred to, "shows that 
the cellular tissue subjacent to the peritoneum is so thin and scanty that 
it is impossible to separate the serous from the uterine tissue ; and that, 
consequently, it cannot be the seat of swellings, which, according to M. 
Nonat's observations, attain, in the space of a few hours, to the size of a 
hen's egg. The only other possible position for the so-called ante- and 
retro-uterine phlegmons is the small band of cellular tissue situate at 
the junction of the neck with the body of the uterus, and this we can 
hardly credit, unless it be proved b}^ an undoubted post-mortem examina- 
tion, which has never yet been adduced. In the absence, then, of direct 
proof, I may be allowed to doubt the existence of this affection as de- 
scribed by M. Nonat. I have for four years asked for proof of this 
proposition ; and, as no one has yet been able to give it, I shall assert 
that the swellings we are now considering, are certainly not formed by 
the inflammation of the thin ring of cellular tissue which encircles the 
upper portion of the neck of the uterus. In the exceptional cases, where 
this tissue is involved in the inflammation of the surrounding parts, it but 
very slightly augments the peri-uterine swellings, and this only when 
there exists also pelvi-peritonitis." It is not here denied, as will be 
observed, that inflammation of the sub-peritoneal cellular tissue occurs: 
it is merely pointed out that anatomical research strongly discredits the 



STRUCTURES INVOLVED. 699 

idea that inflammation is likely to be propagated directly from the uterus 
to the cellular tissue. It would appear that the only situation at which 
the cellular tissue subjacent to the peritoneum has any appreciable thick- 
ness, is where it joins the broad ligaments, — a situation at which all 
authorities admit of the probability of pelvic cellulitis ; and even Bernutz 
himself confesses that phlegmons of the broad ligaments are justly so 
called ; but he points out, at the same time, as an inference from various 
elaborate dissections by MM. Jarjavay and Lefort, that the disposition of 
the various aponeurotic lamellae almost necessarily directs such purulent 
formations as may ensue towards the abdominal walls, or else to the deep 
iliac fossa. 

Aran and Bernutz make a broad but unfortunate distinction between 
iliac abscesses and those which are now under consideration. The his- 
tory of an ordinary iliac abscess is no doubt very diiFerent; but, if we 
are to admit that the sub-peritoneal tissue and the internal genital organs 
are the site of inflammation, it is surely no great stretch of the imagina- 
tion to believe that an abscess which is the result of this may make its 
way into the iliac fossa, so that, while originating within the true pelvis, 
the bulk of the resulting tumor is actually abdominal rather than pelvic. 

What we owe chiefly to Bernutz, is the clear demonstration of the fact, 
that a large proportion of so-called cases of pelvic cellulitis are not so at 
all, but that the symptoms are due to circumscribed inflammation of the 
pelvic peritoneum. This pelvi-peritonitis is, as we have said, identical 
with the perimetritis of ^latthews Duncan. " I conclude," says Bernutz, 
" that inflammation of the pelvic serous membrane is always symptomatic, 
and that it is generally symptomatic of inflammation of the ovaries or Fal- 
lopian tubes. Thus great interest attaches to the study of this affection; 
and it is very important thoroughly to understand the symptoms, in order 
to describe satisfactorily the uterine, and more especially the tubo-ovarian 
diseases which occasion it." By pelvi-peritonitis, then, we understand 
an affection which is essentially a secondary or symptomatic one, — the 
inflammation originating, according to Bernutz, in the uterus, tubes, or 
ovaries, and extending thence to their peritoneal investment. It is diffi- 
cult to understand how the disease can spread in this manner without 
involving the intermediate cellular tissue, but the difficulty is very simply 
solved by Bernutz, by the denial that any such tissue exists over the 
uterus, except at the site already alluded to between the layers of the 
broad ligament. That this is the case we very much doubt, and, although 
it may be extremely thin, all analogy would lead us confidently to expect 
that a trace at least of cellular tissue must there be discoverable. That 
the peritoneal affection in these cases is secondary to inflammation of the 
subjacent organs is a fact which, in regard at least to the majority of 
cases, he has succeeded in establishing ; but we do not think that he is 
warranted in assuming that pelvi-peritonitis can be produced in no other 
way. In some cases, the result has been the formation of cysts in the 
peritoneum, which are circumscribed by the inflammatory process, and 
may contain a purulent or muco-purulent fluid. In others, the tumor — 
the nature of which during life it had been impossible to determine — was 
discovered, on post-mortem examination, to consist of a mass of viscera 
matted together by adhesions, usually involving the tube and ovary with 



700 PELVI-PEEITONITIS. . 

contiguous portions of the bowels. The diagnosis of this latter class of 
tumors is particularly difficult, as the structure of the mass is such as to 
render almost useless the valuable information which we obtain in other 
cases from fluctuation and percussion. Another point of importance, in 
reference to such cases, is the possibility of a mechanical obstruction to 
the function of that part of the boAvel which is involved. 

In a case seen with Dr. Moore, this appeared to us to be the cause of 
the severity and alarming nature of the symptoms. The patient had 
been confined about a month previously, and being out for her first drive, 
she imprudently got out of the carriage, and sat for a short time on a 
bench in an exposed part of the park. On her return home she felt 
unwell. The following day acute pain was complained of in the left side 
above the groin, and the symptoms generally went on increasing in 
severity, while a tumor became developed in the region referred to. 
This tumor was irregular in shape and indistinct in outline, but, being 
exquisitely tender, it was difficult to make a satisfactory examination of 
it, further than that it was manifestly connected with a corresponding 
fulness which was easily recognized from the vagina. It was with the 
greatest difficulty that the action of the bowels was maintained: the tym- 
panitic distension was enormous, and for some days the occurrence of 
obstinate vomiting prevented the administration of any remedies, or 
almost of any food by the mouth. Considerable benefit was derived 
from the use of suppositories containing tar, but it was on several occa- 
sions found necessary to give egress to the pent-up flatus by the use of 
O'Beirne's tube. Ultimately, after a long and anxious illness, this lady 
recovered, and the tumor disappeared. 

We have here to do only with those cases of pelvi-peritonitis which are 
associated with the puerperal state, which constitute, indeed, nearly a 
half of all cases from whatever cause arising. The disease, of course, 
originates, in almost all of this class of cases, in the uterus, and the aff"ec- 
tion is therefore one of metro-peritonitis ; and this portion of the perito- 
neum is the more likely to be the seat of the lesion, the sooner the symp- 
toms are developed after delivery. If after a longer interval, the chance 
of its being inflammation of the appendages is proportionally greater. 

In attempting to form a diagnosis between pelvi-peritonitis and pelvic 
cellulitis, the following are among the more important points which it is 
proper to bear in mind. In the former, the affection is usually, though 
not invariably, limited to the true pelvis, and may be distinctly recog- 
nized from the vagina ; in the latter, the true phlegmon, originating in 
the cellular tissue, cannot be reached from' the vagina, but, tending to 
spread towards the iliac region, can usually be made out by hypogastric 
palpation at an early stage of the case. The tendency to the formation 
of abscess and discharge of pus is greater in cellulitis than in peritonitis, 
so that the symptoms indicating the formation of pus may come to be of 
some importance in doubtful cases. If it be correct to assume that pelvic 
cellulitis, when it follows labor, generally originates in the broad liga- 
ments, we can have no difficulty in understanding how tumors, originating' 
in pelvi-peritonitis, and thus being intimately connected with the uterus, 
are not only more within the reach of the finger, on examining per vagi- 
nam, but are frequently found to produce very marked displacement of 



FORMATION OF ABSCESS. 701 

the uterus in proportion to the size of the swelling. In the more chronic 
variety, the diagnosis of pelvi-peritonitis may involve doubts as to the 
nature of the tumor which is recognized from the vagina. The difficulty 
is supposed to be greatest in the case of the affection which has been 
termed " engorgement of the uterus" in which the tissue proper of the 
uterus is increased in volume ; but the regularity in these cases, in the 
outline of the tumor, its mobility, its firm consistency, and the transmis- 
sion downwards of movements communicated to it from above, will prob- 
ably serve to enable us to form a pretty confident opinion. Uterine 
displacements of various kinds and fibrous tumors may also be mistaken, 
and erroneously supposed to be tumors, the result of pelvi-peritonitis. 

The formation of an abscess is probably the result which, in puerperal 
cases, we look to with the greatest apprehension. It is only since Ber- 
nutz's investigations that it has been fully recognized that pus may 
accumulate in the form of abscess, not only in the cellular tissue but also 
within the peritoneum. This, indeed, forms a most important practical 
analogy between pelvi-peritonitis and the familiar pelvic cellulitis of most 
writers. The majority of all pelvic abscesses, occurring at the period of 
which we speak, are probably due to the latter affection ; but some of 
our most able gynaecologists hold a contrary opinion, and believe that 
intra-peritoneal purulent collections form the majority of grave abscesses 
in this situation. Supposing it to be admitted that the idea generally 
entertained as to the origination of pelvic-cellulitis within the folds of 
the broad ligament is well founded, an interesting subject of investiga- 
tion is thus suggested. Nor can we wonder that numerous dissections 
have been made, and experiments by injection or inflation of the 
cellular tissue performed, with the view of determining what direction 
an abscess in this particular situation is likely to take. The question is, 
however, far from solved, and we certainly find abscesses taking quite 
unexpected directions. " The most frequent extension of parametric 
abscesses," writes Matthews Duncan, " is either upwards, or into the 
iliac fossa on either side. But they may go much further. They may 
extend along the rectum to the perineum. They may extend to the 
kidneys. They may, in assuming these directions, attack only cellular 
tissue, or, in addition, may lead to destruction of muscles, as of the 
psoas and iliacus. I have dissected such abscesses in the puerperal 
state, and in connection with non-puerperal disease, extending from the 
kidney to the uterus." It is well known that these abscesses sometimes 
burst into the rectum, bladder, or vagina, and the detection of pus in the 
feces or in the urine may afford the first clear evidence of the nature of 
the case. The opening into the rectum, indeed, is one of the most favor- 
able terminations of such an abscess. The opening into the bladder may 
determine a troublesome urinary disorder, but is not so unfavorable as 
might perhaps have been supposed. Fortunately, the opening into the 
peritoneum is of rare occurrence. 

One of the most important practical points connected with these 
abscesses, whether they be parametric or perimetric, is the method to be 
employed for the detection of pus. Every clinical student is taught 
that fluctuation is the most reliable sign of the presence of fluid within 
a cavity which it fills, and is instructed how to apply the test, the 



702 PELVI-PERTTONITTS. 

manipulation being somewhat varied according as the accumulation is 
large as in ascites, or small as in an ordinary superficial abscess. In 
this strict sense, however, fluctuation is very rarely available in the 
diagnosis of pelvic abscess, for the obvious reason that while we require, 
to produce real fluctuation and at the same time to appreciate it, two 
hands, — as a rule, in the investigation of these tumors, one hand, or it 
may be one flnger only, is available. The circumstances under which 
actual fluctuation is then discoverable are to be found in those cases only 
in which the tumor has reached above the pelvic brim in the direction of 
the iliac fossa or elsewhere, or when it is possible to produce the wave 
of fluctuation between the fingers in the vagina, and the other hand 
applied to the abdominal wall. The presence of fluid may, however, 
often be recognized quite easily by the finger in the vagina ; but there 
are many cases in which to be certain requires a high degree of the 
tactus eruditus. " This is, however," as Dr. Duncan observes, " not 
feeling fluctuation. It is merely the educated finger picking up such 
sensations as enable the mind to perceive a collection of fluid in a cyst 
or bag. The finger cannot both produce fluctuation and feel the shock 
of the wave." 

Treatment. — The management of pelvic cellulitis and pelvi-peritonitis 
depends, in the first place, and very obviously, upon the nature of the 
case. It will depend, moreover, upon whether the symptoms are acute 
or chronic ; whether the disease is progressive or stationary ; and 
whether there is already evidence of the formation of an abscess. It is 
quite clear, therefore, that, on many points, the ordinary principles of 
surgical treatment must be our guide ; but, in so far as the treatment 
to be pursued is identical with what a moderate acquaintance with 
clinical surgery would indicate, we shall not follow the subject. There 
are, however, many special practical considerations, most of which ex- 
perience alone can teach ; but to one or two of these we may here 
briefly advert. Of the symptoms which call for prompt treatment, 
none is of more importance than local pain. If the seat of the pain 
reaches above the brim, nothing is more grateful to the feelings of the 
patient than the application to that region of poultices and fomenta- 
tions, which may be sprinkled with laudanum, or otherwise modified to 
suit the exigencies of the case. When the tumor is more truly pelvic, 
and can only be felt from the vagina, the vaginal douche sometimes 
gives temporary relief, and in other instances medicated pessaries, such 
as were recommended by Sir James Simpson, may be employed. Ber- 
nutz strongly advocated the internal use of conium, and it may even be 
necessary to use some of the preparations of opium. 

The sufferings of the patient are sometimes greatly aggravated by the 
pressure which the tumor exercises on neighboring viscera, especially the 
bladder and the rectum, when the function of these parts may be seriously 
interfered with. The exact nature of this class of symptoms will entirely 
depend upon the anatomical relations which the tumor bears to contiguous 
parts. When the pressure is forwards, in the direction of the pubic sym- 
physis, the suffering from pressure upon the neck of the bladder is some- 
times excruciating, and as one result of this may be constant calls to 
micturate, which is often effected with difficulty, the pain which is thus 



TREATMENT. 703 

produced may be intense. In some instances, the bladder can only be 
emptied by the regular use of the catheter. When the pressure takes 
the other direction, the suffering is not so severe, but there is almost 
always more or less pain in the back. In some cases, there is obvious 
mechanical interference with the function of the bowels, the difficulty in 
the act of defecation, and the flattened condition of the feces, showing 
clearly the nature of the case. In other instances, there is apt to be 
obstruction of a more serious nature, as in pelvi-peritonitis, involving the 
bowel, when the patient suffers much, both from obstruction and from 
flatulent distension. In every such case, the action of the bowels should 
be scrupulously watched, and, on the slightest sign of obstruction, imme- 
diate means must be taken to prevent the possibility of serious results, 
by the combined action of laxatives and enemata. A simple injection of 
soap and water, with or without turpentine, may, in such cases, be given 
every night, — a mode of practice which will, in many instances, contribute 
to the comfort of the patient. 

The treatment, generall}^, of a case will divide itself into the arrest of 
inflammation, the promotion of absorption, and the discharge of pus when 
abscess has actually formed. It is with the view of fulfilling the first of 
these indications that blood-letting, in such cases, is usually recom- 
mended. Few persons will, probably, think of general blood-letting. It 
is, at least, difficult to conceive a case in which the circumstances would 
warrant such a measure. It is otherwise, however, as regards leeching, 
from which, in some instances, very marked and decided benefit may be 
anticipated. Leeches may be applied to the groins, the perineum, or the 
uterus ; but, although blood drawn from any of these situations may be 
productive of excellent results, it is obvious that the direct abstraction of 
blood from the uterus, — more especially if that organ is involved, prima- 
rily or secondarily, in the morbid action, — is the procedure from winch 
w^e may anticipate the most marked effect. But, if the nature of the case 
be such that it is impossible to introduce the speculum, the leeches may 
be applied to the vulva, taking care that they do not bite too high ; for it 
has happened that very troublesome bleeding has been the result of the 
application of leeches to the vagina, from the difficulty of reaching and 
controlling the bleeding point. "I believe," says Bernutz, "that four 
leeches applied to the cervix are as good as three times that number ap- 
plied externally ; for, not only is it nearest to the seat of inflammation, 
but the relief to all the genital organs is greater. I do not think even 
scarification can be compared with leeches, in point of utility; the amount 
of blood drawn off is, comparatively speaking, quite insignificant; and 
there is the possibility of serious consequences resulting. 

It is never necessary to apply more than three leeches at a time to the 
OS and cervix, for if the quantity of blood which is withdrawn should not 
be deemed sufficient, the flow may be encouraged by a warm hip-bath, 
by means of which the quantity may often be regulated at will. As a 
rule, it is not advisable to aim at the abstraction of a large quantity of 
blood, as a very moderate discharge is all that is necessary thoroughly 
to deplete an organ of the size of the womb ; but, besides this, there is 
the danger of interfering with the menstrual function, should we push 
depletion too far, — more especially if the period be at hand. In the 



704 PELVI-PERITONITIS. 

actual application of the leeches, some nicety of manipulation is some- 
times required, to prevent them from crawling round the edge of the 
speculum, when they will probably fix upon the vagina, or even pass out 
by the vulva ; and, as it has happened that disagreeable symptoms have 
resulted from the leech making its way into the uterus, it is recommended, 
in pluriparae, or in any case where the aperture is large, to put a small 
plug of wool in the gaping os. It is to the acute stage, mainly, of the 
cases of pelvi-peritonitis, in which the uterus or its appendages are 
assumed to be the original seat of the disorder, that leeching is applica- 
ble ; but there are, undoubtedly, cases of cellulitis in which congestion 
of the womb exists as a complication, where the treatment is precisely 
similar. And, at any stage of the more chronic forms, an exacerbation 
of the symptoms may present such features as clearly to call for local 
depletion. In the present state of our knowledge, it will not do to pause 
in these cases until our diagnosis is complete. The indications which 
point to blood-letting as the proper remedy at the time being clear, it is 
a very secondary matter to determine whether the peritoneum or the 
cellular tissue is the part involved. 

Poultices, fomentations, hip-baths, and the vaginal douche, are ex- 
tremely valuable agents in these as in other affections, in controlling 
inflammatory action, and, as has already been observed, in alleviating 
pain. But the fact is, that there is no stage of the disease at which 
this class of remedies may not be found beneficial. They should be 
employed continuously in the acute stage ; and, in the case of an abscess 
which threatens to point externally, the application of poultices may 
also be diligently carried out. In cases w^here the result of the inflam- 
matory action has been the formation of a tumor, or more diffused hard- 
ness, it comes to be a question whether nothing can be done with the 
view of promoting absorption. At one time, when the professional 
belief in mercury was unbounded, that drug would naturally have 
suggested itself as an essential part of the treatment, either in the acute 
stage, in that of which we are now speaking, or in both. It must be 
confessed, however, that comparatively little faith is now placed in mer- 
cury as a remedial agent. Many reject it absolutely, in this and other 
diseases ; but in so passing from the abuse to the absolute neglect of the 
drug, we think that the modern physician, as in the case of general 
blood-letting, has gone too far. We should certainly recommend that 
the patient may have the chance which such a remedy aff'ords her ; but, 
if there be anything to contra-indicate the use of mercury, it may be 
abandoned with less regret than if we had more faith in its action. The 
most suitable preparation is the perchloride, which may be administered 
in doses of -^^ of a grain, and should never be carried beyond the stage 
at which the gums, &c., indicate faintly commencing mercurialization. 

Iodine is another remedy of the same class, which many will employ 
with less hesitation, either in the form of iodide of potassium internally, 
or, it may be, by the external application of the tincture or ointment. 
The latter may be applied when the tumor is hard and chronic, and 
can be easily recognized through the abdominal walls ; or they may be 
employed in similar circumstances through the vagina, a method of 
treatment which has been found beneficial in many of the uterine dis- 



TREATMENT. 705 

orders familiar to the gynaecologist. Blistering has been strongly advo- 
cated by some after the acute stage is past, and no one will deny that 
experience would encourage us to look to this mode of treatment for 
satisfactory results ; but we confess to a preference for the external 
application of iodine, by which irritation may be maintained for a long 
period, its action being, of course, kept within moderate bounds so as 
not to irritate too much. 

In cases in which pelvic abscess has formed, and the ordinary signs 
reveal that pus is present in considerable quantity, it comes to be an 
important practical point whether we are to operate by incision or leave 
the case absolutely to nature. In so far as can be gathered from the 
experience of modern practice, abscesses, wherever existing, are now 
much less frequently opened than was the ordinary practice of a quarter 
of a century ago. But, whatever be the case as regards ordinary sur- 
gical practice, it is certain that, in the management of pelvic abscesses, 
particular care and discrimination is necessary. Caution is more im- 
peratively demanded when the tumors show a tendency to point in 
the groin or elsewhere above the pelvis ; but it must at the same time 
be remembered that, while the danger of premature operation is ad- 
mitted, the greater danger of rupture of the sac and escape of its con- 
tents into the peritoneal cavity must not be overlooked. Some have 
said that such an abscess should be opened when it threatens to burst 
into the peritoneum ; but in what this threatening consists, or how we 
are to recognize the danger, is what no one has attempted to show. If 
the abscess is acute in its history and progress, it is better to leave the 
operation to nature ; but, if it is mature and chronic, and shows no 
tendency to point externally, it comes to be a very delicate matter to 
determine whether we shall operate or not. If we dread its opening 
into the peritoneum, we must at the same time bear in mind what the 
experience of West, Bernutz, Aran, and others has clearly shown — that, 
even if we open an abscess, this does not prevent its subsequent perfora- 
tion into the peritoneal cavity. If the symptoms of hectic fever mani- 
fest themselves, or if the tumor gives rise to great suffering, the idea of 
operation will naturally receive encouragement ; but, in the absence of 
these conditions, it is always better to wait. Pelvic abscesses may 
point at various situations externally, which are well known to the sur- 
geon, or they may only be reached through the vagina, or even by the 
rectum, and in doubtful cases the preliminary use of the aspirator may 
be indicated ; but, in most cases, when the operation is resolved upon, 
the opening should be free so as to admit of a thorough evacuation of 
the cyst, availing ourselves as far as possible of the ordinary antiseptic 
precautions. '^ Old pelvic abscesses," Dr. Duncan observes, " demand 
even boldness in operating. ... I have repeatedly operated in 
cases where I knew the abscesses were several years old ; and in such 
cases sometimes more than once ; and I have never had reason to doubt 
the propriety of the treatment." 

There is another class of pelvic tumors, the nature of which was- 
recognized by Ruysch in 1691, but which has received very little atten- 
tion except at the hands of quite modern gynaecologists. These are the 
sanguineous tumors — the result not unfrequently of menstrual accumula- 
45 



706 SUDDEN DEATH. 

tion outside of the uterus — to which the name of Peri-uterine Il^enato- 
cele has been given. This question is too complicated to enter upon here, 
and, indeed, there is only one section of it — the intra-pelvic hemorrhage 
occurring in extra-uterine pregnancies — which comes strictly within the 
scope of our subject. These tumors are merely mentioned at this place, 
as they might possibly give rise to difficulties in the diagnosis of the 
affection which we have just been considering. 

Sudden death in the puerperal state is a subject which of late has 
attracted considerable attention, more particularly since the phenomena 
of thrombosis and embolism have been more thoroughly understood, as 
these are undoubtedly the cause of death in a large number of the fatal 
cases. 

In the course of puerperal fever, as has already been stated, what we 
may call septic embolism is by no means of unfrequent occurrence. 
Among other localities, the detached clot may lodge in the pulmonary 
artery and its branches; and this is, no doubt, the cause of the secondary 
abscesses found in the lungs in certain cases of puerperal pyaemia. If a 
small branch only is occluded, the symptoms are correspondingly slight, 
but if the main trunk or a large branch is blocked, death may either be 
immediate, or may occur after an interval, during which the leading 
symptoms are precordial oppression, dyspnoea, cyanosis, and a low tem- 
perature. 

But it is not only in the course of a case of septicaemia that embolism 
may occur. The highly fibrinated condition of the blood, natural to the 
normal condition of the woman at this period, may be still further in- 
creased as the result of exhausting hemorrhage, a condition manifestly 
favorable to the formation of thrombus, and the subsequent accident of 
embolism. The connection of phlegmasia dolons with pneumonia and 
pleurisy has already been mentioned incidentally, but there is good reason 
to believe that attacks of so-called pneumonia in puerperal women, par- 
ticularly when they occur in the course of phlegmasia dolens, are usually 
due to hemorrhagic infarctions brought about by the transmission of a 
clot from the veins to the right side of the heart, and thence to the pul- 
monary artery. The symptoms of such an illness, with rigors, high 
temperature, h&emoptysis, and cough, very closely resemble those of 
pneumonia, and the physical signs reveal congestion and consolidation of 
the lung : not unfrequently pleurisy, Avith more or less effusion, compli- 
cates such hemorrhagic infarctions. In the further progress of the case 
there may be evidence of the destruction of a limited portion of the lung 
or of the formation of a localized pulmonary abscess. 

The following account, condensed from the notes supplied to the writer 
by Dr. E. M'Millan, affords a remarkable instance of the recurrence of 
pleuro-pneumonia in the puerperal state, due in both instances, no doubt, 
to embolism of the pulmonary artery, although the first illness was not 
regarded in this light at the time. 

A primipara, 31 years of age, was confined at term on November 28th, 
1874: there was no complication of any kind in the labor. Ten days 
afterwards she had pain in the calf of the right leg^ without any marked 
swelling. Fifteen days after her confinement she had pain in the lower 



THROMBOSIS. 707 

part of the left lung posteriorly, this became very acute in a few hours 
and resembled a pleuritic stitch ; subsequently rusty expectoration and 
dulness on percussion supervened, and the diagnosis of pleuro-pneumonia 
was made; the case was not very severe, and she began to improve 
quickly, and was pretty well by January 1st, 1875. On this day, how- 
ever, severe pain began in the left leg, and swelling supervened as in 
well-marked phlegmasia dolens; this part of the illness lasted a month. 
(A fatal case of scarlet fever occurred in the house about this time; the 
child, however, took ill a day or two after the lady began to complain of 
pain; the patients were completely separated, and so far as appeared 
there was no connection between the two illnesses, the child having evi- 
dently contracted the fever at school.) 

Her second confinement occurred on xipril 10th, 1877 ; the labor was 
short and natural. On April 11th, early in the morning, she had a severe 
rigor and was feverish and excited, with at times a feeling of faintness ; a 
slight shivering occurred in the forenoon, and another rigor, more severe, 
at night, lasting twenty minutes ; she felt very ill and thought she was 
dying ; there was no pain over the uterus or anywhere else ; up till this 
she had been nursing the baby, but the milk now ceased. On the fol- 
lowing day the temperature continued high, 103"^ in the evening. Next 
day, April lGth,the temperature reached 105° in the morning, and after 
falling a little, mounted to 104° in the evening, when there Avas another 
shivering. Next morning, April 17th, the temperature had fallen to 99°, 
but in the evening another rigor occurred, and the temperature rose again ; 
cough and rusty expectoration now began, and she complained of pain in 
the back and in the left side of chest; physical examination showed 
signs of consolidation and pleuritic effusion on that side. Thereafter the 
fever continued in a somewhat remittent manner for a month ; the expec- 
toration, of bloody character, contii^iued more or less all that time, some- 
times lighter sometimes darker in color. She was often troubled greatly 
with the cough, and sweating became a prominent symptom in the case. 
Occasionally the expectoration was very profuse, and at times noted as 
creamy. The subsequent part of the illness was complicated by partial 
pneumonic consolidation on the right side, by slight sore throat, and a 
small superficial mammary abscess ; but she was able to sit up a little 
by the month of June, and made a complete recovery. The physical 
signs in the chest disappeared slowly. 

According to Dr. Playfair,^ who has devoted great attention to the 
question of thrombosis of the pulmonary artery, we may find the symp- 
toms of obstruction in the pulmonary circulation before the appearance 
of phlegmasia dolens, and he argues with considerable plausibility that 
the process of thrombosis in such cases had begun simultaneously in the 
pulmonary artery and the iliac vein, as some time is required for the 
development of the swelling of the leg. Of course the facts are open to 
another interpretation, that the symptoms of mischief in the chest were 
due to the displacement of clots from the uterine or other veins at the 
very commencement of the venous thrombosis which was leading up to 
the phlegmasia dolens. 

The same writer contends strongly for the view that very serious or 

1 A Treatise on the Science and Practice of Midwifery, London, 187^, vol. ii. 



708 SUDDEN DEATH. 

fatal obstruction of the pulmonary artery is frequently due to thrombosis 
rather than embolism, and points out that the cases may be divided into 
those in which the fatal mischief occurred within a few days after labor, 
and those in which an interval of two or three weeks elapsed ; in the 
latter group, evidence of embolism was presented by the post-mortem 
examination, and he considers that some time is required for changes to 
be developed in the clot to favor its detachment and transmission as a 
plug ; in those cases, on the other hand, where death occurred early, he 
contends that there was no evidence of embolism, and that the more 
probable pathology is the formation of a clot in the pulmonary artery 
itself. This question is a complicated one, for we may have a small 
embolus forming the nucleus of a large thrombus, and a thrombus in the 
pulmonary artery not sufficient to cause very serious consequences may 
suddenly present a fatal obstruction when the remaining space is blocked 
up by an embolic clot. 

When the clot is large enough to present a serious obstruction, the 
symptoms are those of the most sudden and aggravated dyspnoea, cha- 
racterized by gasping and struggling for breath, associated sometimes 
with pallor and sometimes with lividity, the heart's action is tumultuous, 
and the pulse extremely small ; death may result in a few minutes. It 
is worthy of note that this fatal accident often occurs without anything 
to warn us in any way of impending danger, and it seems frequently to 
have taken place in connection with some exertion, as on rising from 
bed, arranging the hair, &c. Some of the patients appear to have 
recovered from this formidable accident, and the treatment to be 
adopted, if medical aid can be procured m time, is by very free stimu- 
lation of all kinds, and by the exercise of the most extreme caution as 
regards exertion. 

Cerebral embolism is also an occasional cause of sudden death in the 
puerperal woman, but, even when rapidly fatal, there is not the extreme 
suddenness which is observed in the accident which has just been re- 
ferred to. Several interesting cases of cerebral embolism after parturi- 
tion have been narrated by Hughlings Jackson, Fordyce Barker, and 
others : as in other cases of this lesion, the middle cerebral artery on the 
left side seems to be the most frequent site, and so we find that aphasia 
is one of the symptoms occasionally observed. From two cases recently 
under the observation of Dr. Finlayson in the Glasgow Western Infirmary, 
it would appear that there may be a repetition of this accident ; both of 
the women referred to suffered from aphasia, which came on within a few 
days after labor; and, after making a tolerably complete recovery, both 
were seized after their next labors with a very aggravated and persistent 
form of the aphasia ; in one of the cases the right hemiplegia was extreme, 
but in the other it was slight.^ 

The entrance of air into the veins is well known to be a cause of 
sudden death. There is no doubt that the provisions of nature after 
delivery are not such as to favor the ingress of air to the uterine 
veins ; but it has been demonstrated that, under a certain degree of 
pressure, it is possible, and it is believed by some to be a rare cause of 
sudden collapse. 

1 Glasgow Medical Journal, September, 1879. 



ANESTHETICS. T09 

Thirty years ago, no one could presume to write a treatise on 
Midwifery without an elaborate disquisition on the subject of An- 
sesthesia. The then recent discovery of chloroform and of the 
anaesthetic power of sulphuric ether was an era in the history of 
surgery ; and we cannot wonder that the obstetrician should have 
claimed for his art the immunity from pain and the other advantages of 
which his surgical brethren were so gratefully availing themselves. We 
look back to this period Qcirca 184:8), and turn over the pages of the 
pamphlets which mark the bitterness of the controversy which was 
then being waged, with a feeling partly of amusement and partly of 
humiliation. The theological tone which was prevalent in some quarters 
is the most extraordinary feature in the whole affair ; but how sensible 
and able men could write such trash, and argue gravely against the 
iniquity which was being perpetrated in relieving women from the effects 
of the Divine curse " {)i dolore paries ^^^ will ever remain an inscrutable 
psychological phenomenon. 

There are many agents which have been classed as ancesthetics, and 
there no doubt are many more. At present, ether and chloroform are 
the only two which are habitually employed ; and to these we may per- 
haps add chloral, as it is now pretty well known that a patient, thoroughly 
under the influence of this drug, may go through the whole stages of 
labor without any sensation of pain or any consciousness of the process 
which is going on. Ether and chloroform, however, the one in America 
and the other in this country, are, from the evanescent nature of their 
effects, preferred to those agents whose operation is more permanent, and 
after which disagreeable results are more likely to accrue. At first, 
partly from the impulse and surpassing interest given to the subject by 
its eminent discoverer, chloroform was used somewhat indiscriminately in 
cases of labor which were in all respects normal ; but subsequent expe- 
rience has shown that such wholesale use of aniTesthetic aoiients cannot be 
supported, either by argument or by practical experience. 

The result of numerous experiments has proved that chloroform, which 
is sparingly soluble in the blood, travels through the circulation in con- 
siderable quantity, in an uncombined state. It having a strong affinity 
for oxygen, the ordinary chemical changes which normally take place in 
the blood, are thereby materially interfered with, and Dr. Snow has 
shown that, in consequence of this, the quantity of carbonic acid evolved 
from the luno;s is materially diminished. Such an effect, if of short dura- 
tion, will probably produce no very serious result upon the economy ; 
but should the action be unduly protracted — which is necessary, if we 
wish absolutely to annihilate pain in labor — 'We can well imagine that the 
ultimate results may be in some way or other unsatisfactory. It has 
frequently been observed, and many have noted it as a remarkable fact, 
that the effect of chloroform does not seem in any way to arrest or even 
to modify the expulsive efforts ; but, if we bear in mind what has been 
said in regard to the reflex action produced by an excess of carbonic acid 
in the blood, the experiments of Dr. Snow afford a ready explanation of 
this, which was at one time supposed to be a phenomenon, unique in 
itself, and of great interest. 

The effect of chloroform on the nervous system is, however, the point 



TIO ANESTHETICS. 

in regard to which, in the practice of midwifery, the greatest amount of 
interest attaches. In the view which we take of the subject, by far the 
most important point is that a moderate dose of chloroform may annul, or 
at least deaden sensation, Avithout disturbing the power of motion or con- 
sciousness. This enables us to alleviate the sufferings of our patient by 
a trifling dose, and without bringing her fully under the influence of this 
powerful agent. The interference, therefore, with the chemical changes 
which are constantly going on in the blood is proportionally diminished. 
The further we push the administration of chloroform, or of the other 
anaesthetics, the more thoroughly is the cerebro-spinal or reflex function 
influenced, until at last the motor fibres of the respiratory nerves are 
affected, and stertor indicates that the Ultima TJmle of safety has been 
reached. 

The disadvantages of chloroform in the practice of obstetrics are, in 
the first place, the tendency to vomiting, which is so apt to be produced 
in the course of its administration. For obvious reasons, however, the 
stomach rarely contains much food at the period of delivery, and this is 
no doubt the reason why vomiting is, in midwifery practice, comparatively 
rare. Still, it does occur ; and more than that, it occasionally persists 
for a considerable time, to the manifest disturbance of the patient during 
the post-partum period. Partly on this account, and partly, it may be, 
in consequence 6f the effect which is produced on the nervous centres, it 
has been pretty clearly established that the indiscriminate use of chloro- 
form, or other anaesthetics, predisposes to hemorrhage after delivery. 
Another danger of chloroform is the tendency to failure of the heart's 
action, which is often so rapidly and unexpectedly produced, especially 
when deep anaesthesia has to be effected. This failure of the heart's 
action and of the blood pressure in the arteries is much less liable to 
occur during the use of ether, and the writer has much pleasure in refer- 
ring to the important results obtained by the experiments of his colleagues 
who have recently reported on this subject to the British Medical Asso- 
ciation.^ Another objection which has been stated is perhaps of less 
importance — that in operations, the annihilation of sensation removes what 
Avas before a reliable safeguard, as, for example, when the blades of the 
forceps are applied, the patient is no longer conscious of the pain caused 
by including a portion of the vaginal mucous membrane in the lodk — the 
suffering produced by which would previously have caused her to cry out. 

The question of anaesthetics seems to us to stand thus. In eclampsia, 
in some cases of mania, in all cases of operative midwifery, and especially 
in many cases of turning, they are, without exaggeration, invaluable. 
In ordinary cases, they are always t^ be used with caution ; but if em- 
ployed in small quantities on a handkerchief on the approach of each 
pain, towards the termination of the second stage, they can never do 
harm. They thus allay pain and assuage nervous irritability, and, in the 
hand of the skilful practitioner, they are a power for good and never for 
evil. 

' Reports on the Action of Ansesthetics, bv Joseph Coats, M.D., William Ramsay, 
Ph.D., and John Gr. M'Kendrick, M.D. British Medical Journal, Jan. 4, Jan. 25, and 
June 21, 1879. 



APPENDIX. 



THE BI-PARIETAL OBLIQUITY OF NAEGELE. 

For reasons which have already been stated, but chiefly with the view 
of avoiding controversial matters in the text, I have thought it better to 
express, in the form of an appendix, the reasons which have led me to 
reject the theory of bi-parietal obliquity as an element in the mechanism 
of parturition. The following observations, with some modifications, are 
mainly taken from my work on the "Mechanism of Parturition," pub- 
lished in 1864. The error of Naegele is certainly not so commonly taught 
as it was once, and many distinguished teachers and writers have com- 
pletely abandoned it ; but the fact of its still being a matter of common 
belief, together with the respect which is due to any doctrine having the 
stamp of the authority of the distinguished Professor of Heidelberg, 
makes it both necessary and fitting to analyze the subject with some care. 
But as some doubt has occasionally arisen in regard to the exact nature 
of Naegele's views, it will be proper first to make sure Avhat his opinions 
were before proceeding to refute them. 

In his celebrated essay, originally published in MeckeVs ArcMv^ Nae- 
gele describes, in addition to the pelvic and occipito-frontal obliquities, a 
third obliquity, the bi-parletal. He maintained, that, in regard to its 
transverse measurement, the head entered the brim obliquely, " so that 
the greatest breadth of the skull (from one tuber parietah to the other), 
as also the breadth of its base, never in its passage under ordinary cir- 
cumstances, coincides with the diameter of the brim." On this point he 
says also, in describing the first position: — 

'' The head, has not at the brim a direct hut a perfectly oblique position, so that the 
point which lies lowest or deepest is neither the vertex nor the sagittal suture, but 
the right parietal bone. The sagittal suture is nearer to the promontory of the sa- 
crum than to the pubis, and divides the os uteri, which is directed backwards, and 

generally somewhat to the left, into two very unequal parts The higher 

the liead is, the more does its long diameter approach the transverse of the brim, and 
the more oblique is its position, on account of which the right ear can generally be 
felt without difficulty behind the pubis, which would not be the case if the head had 
a perpendicular position." 

These extracts leave no room for doubt that his meaning was really 
a lateral flexion of the head, an approximation of the ear to the corre- 
sponding shoulder. He also describes, but in terms which, being some- 
what vague, have led to some misapprehension, that there is a bi-parietal 
obliquity at the outlet; but in this he is, as has been observed in the 
chapter on the " Mechanism of Parturition," quite correct. The follow- 



712 



APPENDIX 



ing observations, it is proper here to explain, have reference to the cra- 
nial position. 

Bi-parietal obliquity. — 'It will be understood that, in considering the 
second kind of obliquity — that, to wit, by means of which the head being 
rotated on its occipi to-frontal axis brings the left ear, in the position which 
we are considering, towards the left shoulder — I must, in pursuance of 
my plan, view the head in reference to the axis of the brim alone. The 
presenting point of the cranium I shall consider throughout, until the head 
reaches the floor of the cavity, as that through which the axis of the brim 
passes, its situation being altered only by a variation in the different 
kinds of obliquity. 

Most modern writers, including the many eminent obstetricians of our 
time, agree in adopting Naeo:ele's view with reference to this obliquity. 
It is therefore with much diffidence and hesitation that I here submit a 
contrary opinion, although I have only convinced myself of its truth after 
a careful and laborious study of the progress of labor. I am persuaded, 
that, in a pelvis of ordinary dimensions, the usual course of labor is for 
the head to enter directly in the axis of the brim, with the sagittal suture 
equidistant from pubis and sacrum. The accompanying illustrations show 



Fig. 203. 



Fig. 204. 





In Figs. 203 and 204, the floor of the pelvis has been removed by a section, inclading the greater 
part of the walls of the cavity. In Fig. 203, the head is represented as descending directly in the 
axis of the brim. The dotted circle shows the effect on the apparent position of the os uteri of a 
slight displacement to the side. In Fig. 204, the head is represented as descending in the position 
described by Naegele. 



this more plainly, and in both the observer will remember that he is look- 
ing upwards and forwards^ the axis of vision corresponding to that of 
the brim. The direct position, as here shown, is in most respects the 
same as that which was taught by the leading obstetricians who immedi- 
ately preceded Naegele. He, however, discovered and first announced 
the incontrovertible fact which is set forth in the following words : — 



APPENDIX 



713 



" The finger wliich is introduced in the central or middle line of the pelvic cavity 
and brought in contact with the head, will touch the right parietal bone in the vicinity 
of the tuber .... At the brim the head does not assume a perpendicular, but 
a perfectly oblique position (keinegerade, sondern eine ganz schiefe Stellung), so that the 
jDart which is situated lowest or deepest is neither the vertex nor the sagittal suture, 
but the right parietal bone." 

I repeat that the fact thas stated in general is incontestable, inasmuch 
as it obviously refers to the axis of the cavity ; but Naegele goes beyond 
this, and pushes his conclusions much further than the facts of the case 
warrant, when he says that the sagittal suture is nearer the promontory 
of the sacrum than the symphysis pubis, and that the bi-parietal meas- 
urement can never during labor coincide with the plane of the pelvic 
entrance. I may mention here that, although I began my study of the 
subject with a firm conviction that Naegele was right in this particular, 
I have been step by step driven to the conclusion that he is perfectly 

Fig. 205. 




Fig. 205 shows the great amount of lateral obliquity {qxd the horizon) of the head advancing in the 
axis of the brim, the centre of the sagittal suture being, althouiih much nearer the saeruin, exactly 
midway between the promontory of that bone and the symphysis pubis. It shows also how, during 
the whole of this stage of labor, the right tuber parietale may be described, in general terms, as the 
part which first meets the finger, or as lowest in the pelvis, advancing as it does in the direction of 
the dotted line parallel to the axis of the brim If the head were in the transverse position, the sink- 
ing of the tuber parietale would be still more decided, but in that case it would be slightly to the 
left of the middle line. 

A B, The plane of the brim meeting the horizon at an angle of 66° at A. 

c D, The axis of the brim passing through the centre of the sagittal suture and the coccyx, and meet- 
ing the horizon at d at an angle of 30°. 

wrong. It is perhaps unnecessary to say that the view which I take of 
the position of the head at the brim is, albeit somewhat heterodox, far 
from original. Nor is the doctrine without powerful supporters, as this 
is the view entertained and clearly expressed by Velpeau and Cazeaux in 
France, and more recently in this country by Dr. Matthews Duncan ; and 
several other observers, among whom I may mention Drs. West and Pater- 
son,^ have arrived independently at the same conclusion, which they have 



Glasgow Medical Journal, October, 1862. 



714 APPENDIX. 

expressed in a more cursory but not less decided manner. M. Cazeaux 
describes it as follows — 

"Avant la rupture de la poclie des eaux, la tete du foetus est legerement flechie sur 
le devant de la poitrine, et les rapports des diametres de la t6te avec les diametres du 
detroit superieur sont les suivants ; le diametre occipito-frontal est parallele au dia- 
metre oblique gauclie du detroit superieur ; le diametre biparietal est parallele au 
diametre oblique droit ; la circonferenoe occipito-frontal de la t6te est parallele au 
pourtour du detroit superieur ; I'axe de ce detroit superieur passe par le diametre 
traclielo-bregmatique. ' ' 

The arguments of Naegele on this point are stated, as indeed all his 
views are, with great clearness and precision, and are, I admit, appa- 
rently conclusive and convincing. But I do not despair of being able to 
show that he has been led into error, if my readers will only deign to 
put aside for a time a preconceived opinion, and study the subject in 
nature. I may fail in any argumentative attempt to show that Naegele 
was wrong, or I maybe met with reasoning more subtle than my own; but 
I would only ask that as my arguments are founded upon practical research, 
those who would refute them should test the matter fairly — a test which 
will involve some labor, but which is within the power of every practi- 
tioner in midwifery. 

In admitting the general accuracy of most of Naegele's descriptions, I 
assume that the fundamental error from which, more than any other, his 
mistake arose, was ignorance, at the time he wrote his essay, on the sub- 
ject of the great obliquity of the brim in respect to the horizon. There 
must, I think, have been remaining in his mind some remnant of the old 
idea of the hor-izontal brim; for it must be remembered that his attention 
was not directed to the subject of the relation which the pelvis bears to 
the trunk and limbs, until some years after the date of the publication of 
his paper on the mechanism of parturition. If the brim were indeed 
parallel to the horizon, or nearly so, the fact of the fingar meeting the 
parietal bone in the vicinity of its tuber would be clear and irrefragable 
evidence of the so-called lateral or bi-parietal obliquity of the head. 
But if we do not allow ourselves to lose sight of the fact that the brim is 
inclined at an angle of 60°, and that the vertex or presenting part passes 
downwards and backwards so obliquely as to meet the horizon at an angle 
of 30° — even admitting that the right parietal bone in the vicinity of its 
tuber is the lowest part in the pelvis — I cannot see how this is to be ac- 
cepted as evidence of anything else than that the head is advancing 
directly in the axis of the brim, but very obliquely with regard to the 
cavity, and still more so with reference to the horizon, as is shown in 
Fig. 203. 

If to this great and admitted obliquity we superadd that which, accord- 
ing to Naegele, separates the sagittal suture from the axis of the brim, 
so as to bring the middle part of the suture opposite the fourth division 
of the sacrum; "whether," says the younger Naegele," the head stands 
deeper or shallower," we must first believe that the trachelo-bregmatic 
measurement is as nearly as possible parallel to the horizon. 

The first difficulty which shook my conviction in the accuracy of Naegele's 
statement was here encountered. Granting for the moment that his descrip- 
tion is correct, let any one take a foetal skull and place it in the dried 



APPENDIX. 715 

pelvis in such a position that the vertex is approachins; its floor, with the 
sagittal suture directed as above described, when he will find — and there 
is, I think, no avoiding this conclusion — that the ear could in all circum- 
stances be felt with the greatest ease ; and yet we all know that it is 
almost always a matter of considerable difficulty to reach the ear at this 
stage, even more so indeed than when the head is situated higher. This 
difficulty has not by any means been overlooked by Naegele ; but having 
adopted one fundamental error, he makes this the standard by which he 
gauges deviations from his theory, and thus is inevitably led further 
astray. He explains it thus — "The higher the head is, the more oblique 
is its direction, for which reason the ear can generally be felt behind the 
pubes without difficulty, loliich would not he the case if the head had a 
straight direction ^ 

I admit that on the first blush this argument has a si,2;nificance, which 
it does not, however, maintain on closer examination. In the first place, 
he commits himself to the opinion that this alleged obliquity has no ref- 
erence to the resistance which the head experiences from the pelvis, inas- 
much as it is greater before this resistance can have come into play. He 
then o;oes on to assume that the fact of the ear beino; felt behind the 
pubes at an early stage of labor, is a proof of this obliquity. With ref- 
erence to this point, I would remark that he seems to me, throughout his 
whole essay, to put too much weight on the facility with which the ear 
may be felt at the beginning of labor. That it may in many cases be so 
felt is an undoubted fact; but as far as my experience goes, I have in 
the great majority of cases found it no such easy matter to reach the 
ear, in any stage of labor, as Naegele would have us believe. AVhen I 
can so reach it, it only proves to me, what Naegele himself admits, that 
the head approaches the transverse diameter more than usual. For it 
must be remembered that the upper part of the pubic symphysis is within 
easy reach of the outlet, and that, on account of the inclination of the 
brim, when the ear moves to the side, it moves at the same time upwards 
along the ileo-pectineal line, and consequently further from the finger. 
This then is a mere assertion of Naegele' s ; his proofs are in no degree 
incompatible Avith the idea of a direct entrance of the head. I am quite 
willing to admit that in some extreme cases in which the ear is felt with 
unusual ease, as well as on other rare occasions, there may be some ex- 
ceptional obliquity ; but I am perfectly convinced that this is the excep- 
tion, and the direct entrance the general rule. But there are other argu- 
ments familiar to every obstetrician which must be met, and, if possible, 
refuted. 

"The sagittal suture," says Naegele, "divides the os wtQvi^iuhich jiro- 
jects hacktvards and generallij somewhat to the left, across into two very 
unequal segments." Mark how ingeniously he argues from a preconceived 
opinion, and trims his facts to suit his theory. We may allow the alleged 
inequality of the segments in the mean time to pass ; but as this is quite 
insufficient to account for the amount of obliquity which he describes, he 
maintains that the os is displaced in the very directions which suit his 
argument — viz., backwards and to the left. For it will be observed, on 
reference to Fig. 203, that the effect of a slight displacement to the left 
is, in the direct position at the brim, to throw the small segment for\yards. 



716 APPENDIX. 

and it will be understood at a glance that the further effect of a displace- 
ment backwards would be to leave the sagittal suture concealed by the 
anterior lip of the os; whereas, by bending the head towards the left 
shoulder, his theory restores the relative positions of os and suture. This 
is the flinnsiest of all his arguments, inasmuch as it is purely theoretical, 
and depends entirely for its accuracy on the correctness of his original 
statement in regard to the obliquity. The difficulties in determining the 
relations of the os during labor are very great; but taking, as I do, 
the fact of the sagittal suture crossing the os at the beginning of labor 
as evidence of the direct entrance of the head, I see no reason to doubt 
that the centre of the os corresponds pretty nearly to the axis of the 
brim. I even doubt the general accuracy of the assertion that the smaller 
segment is behind, and I have certainly, at an early stage of labor, found 
it to vary considerably in this respect. Dr. Paterson, who, although 
admitting this fact, is nevertheless convinced that the head enters the 
brim directly, attempts to account for it by supposing that the os is dis- 
placed forwards ; but I rather think that he has no more proof to offer of 
this statement than Naegele had of his, or than I might have if I chose 
to assert that the os was always displaced to the right merely because 
this would suit my purpose. 

The statement which accompanies the above, to the effect that the 
sagittal suture is much nearer to the promontory of the sacrum than to 
the pubis, is equally erroneous. But, with reference to this, a certain 
misapprehension is apt to occur, if we use, instead of the words of Naegele, 
the expression, ''nearer the sacrum," which some modern writers employ. 
For, as a natural consequence of the head advancing in the axis of the 
brim, the suture is beyond all doubt nearer the sacrum; but it is as cer- 
tainly no nearer to the promontory of the sacrum. I think there is no 
one who has a correct idea of the relation which the pelvis bears to the 
vertebral column, and who will introduce his whole hand with a view to 
determine the position of the head at the brim, who can fail to arrive at 
the same conclusion as that which I have attained. For my part, I have 
left no means untried by which this might be tested. On introducing an 
instrument which is well known to surgeons as Professor Buchanan's rect- 
angular staff for lithotomy, I have been able to place the angle on the 
second bone of the coccyx, inclining the short limb until it coincided, as 
nearly as I could guess, with the axis of the brim, when it never failed 
to guide me, if properly placed, to the sagittal suture, or some point very 
near it, on either side. I have even attempted a crucial experiment by 
measuring, by means of a flexible scale, the distance from the sagittal 
suture to the promontory of the sacrum on the one hand, and the pubis 
on the other; and although, for obvious reasons, the results were not so 
accurate as to warrant of themselves any definite conclusion, they certainly 
tended to confirm my belief. 

But the greatest difficulty of all, and the fact w^hich, more than any- 
thing else, seems to confirm Naegele's theory, is the situation in which 
the tumor called the cai^ut succedaneum forms, in those cases in which 
the waters have escaped, and the head is exposed at an early period of 
labor to the pressure of a rigid and undilatable os. On this point I have 
to acknowledge my obligation to Dr. Matthews Duncan, whose researches 



APPENDIX. 717 

on the evidence afforded by the situation of the swellins;, as described by 
Naegele, solved my only remaining doubt on the subject. Every accou- 
cheur has had frequent opportunities of confirming the accuracy of the 
following statement of Naegele's, and which apparently affords striking 
corroborative proof of the accuracy of his assertions: — 

"In certain circumstances, a swelling of tlie cranial integuments forms after the 
OS has begun to dilate, which, in the further progress of labor, when the os changes 
its situation and direction, and the head its position against it, disappears again by 
degrees ; nevertheless, as dilatation proceeds, it may still be felt for some time, 
although much softer. This swelling (in that position of the head which we are 
talking of) is situated upon the right parietal bone, close to its upper edge, and 
equidistant from both angles. Sometimes a small piece extends over the suture to 
the left parietal bone ; its circumference depends upon the degree of dilatation which 
the OS uteri has attained." 

Now this situation of the sw^elling may indicate one of three things : 
The OS may either be inclined forwards ; or it may be subjected to greater 
pressure at certain points of its circumference ; or, again, the head may 
be placed obliquely. Of these, with the proof which I elsewhere have 
of the direct entrance of the head, I consider the last as the most im- 
probable of the three. It must always be remembered that, to account 
for the degree of obliquity described by Naegele, we must adopt in addi- 
tion his theory that the os is displaced backwards and to the left ; but 
nevertheless we must endeavor to account for the fact that the bulk of the 
swelling at least is to be found over the right parietal bone. I have 
already alluded to the theory advanced by Dr. Paterson, that the os is 
inclined forwards, which would, if correct, afford a most satisfactory 
explanation of the phenomena as detailed abov^e. Proof of its accuracy 
is, however, awanting ; and indeed the difficulties which an examination 
offers are such that we cannot hope for a strict demonstration of the fact, 
even if true, unless we were to argue from the assumed fact that the 
entrance of the head was direct, and thus adopt the very error in reason- 
ing which has led Naegele astray. 

The theory by which Dr. Matthews Duncan attempts to account for 
this, demands a separate consideration. This able writer is of opinion, 
that it is a mistake to suppose that the thickest or most prominent part 
of the swelling corresponds to the centre of the area upon which it has 
been formed, but that this is to be found in the direction in which the 
least resistance is offered to its formation. Applying this argument to 
the formation of the swelling in this stage, he says : — 

"The caput succedaneum of the first stage of labor is often formed after the head 
has passed the brim of the pelvis, and is lodged in the upper half of the cavity of the 
bou}'- pelvis. Were we to be cautious and exact in reasoning, all such swellings 
should be excluded from the argument, for evident reasons. It is only those formed 
at the plane of the brim, or very near it that can, under any circumstances, afford 
assistance in settling this question : under the actual deficiencies of exact data, we 
must be content with stating principles. Now it is evident that the direction of the 
caput succedaneum of the first stage will be that of least resistance — that is, the 
direction of the axis of the undilated vagina ; in other words, the caput will be 
thickest where the head is least supported, and may, in other parts within the circle 
of the OS uteri, be so inconsiderable as not to attract notice. Farther, and for the 
same reason, the centre of the caput succedaneum, or the centre of the os uteri, will 
not correspond with the thickest portion of the swelling, but in this case be behind 
it, or near the left parietal bone. The oblique direction downwards and forwards of 



718 APPENDIX. 

tlie vagina will lead the caput in that direction, and the support given by the poste- 
rior wall of the vagina to the posterior half of the space inclosed in the circle of the 
OS uteri will cause thickness of the swelling ov^er the right, and comparative thinness 
over the left, parietal bone, and displacement of the thickest portion of it forwards in 
the pelvis — that is, in the direction of the right parietal and away from the left 
parietal bone." 

This theory is extremely ingenious, and affords to me the only ex- 
planation of the facts described by Naegele, which gives a rational and 
satisfactory solution of the problem, in conformity with the phenomena 
which I myself have observed. For its absolute accuracy I cannot 
vouch ; but I cannot help thinking that it is in the main correct, or at 
least that it points out the direction in which we are to search for truth. 

My last argument is one which, while of itself it goes for nothing, is 
at least admissible as corroborative proof, and is drawn from a consider- 
ation of the cui hoi'io? No such argument would for a moment stand 
against a single observed fact, and we have too many instances of this 
in the history of the subject to permit us to tread otherwise than warily 
on such dangerous ground. But after all we may surely ask what is the 
use of this alleged obliquity? It is not only said to take place before 
the head is actually engaged in the brim, but, according to Naegele, is 
more marked then, and cannot therefore be due to any resistance from 
the hard parts of the pelvis. But, even if it. did not occur till the head 
experienced the resistance of the brim itself, it is difficult to conceive 
what mechanical advantage would result therefrom, as there is ample 
room and to spare in any well-formed pelvis for the biparietal measure- 
ment of a full-sized foetal cranium. In the case of the long diameter of 
the head, we are able, without difficulty, to assign a cause for the ob- 
liquity which causes the occiput to pass in advance of the forehead, but 
in this case I cannot imagine a single theory which will bear examination 
for a moment. I can understand how it may exceptionally occur, being 
rendered necessary by a deformed pelvis, a distended rectum, or some 
other cause : but I am perfectly convinced that the rule in the vast 
majority of cases is, that the head enters the pelvis directly^ in — or nearly 
in — the axis of the pelvic brim. 



INDEX. 



ABDOMEN, appearance of, in pregnancy, 
152 

flattening of, in pregnancy. 152 
Abdominal pain, in pregnancy. 236 

palpation, in pregnancy, 163, 162 

pregnancy, 191 

tumors, diagnosis of, from pregnancy, 152 
Abortion, ciiuses of, 357 

comparative frequency of, 357, 373 

definition of term, 356 

different periods of, 356 

distinction between threatened and in- 
evitable, 364 

distinguished from delayed menstruation, 
363 

expulsion of placenta in, 366 

management of hemorrhage in, 370 

management of placenta in, 371 

retention of the ovum in, 365 

retention of placenta in, 366 

symptoms of, at various periods, 362 

tendency to repeated, 36i 

treatment of, 367 

treatment after, 373 

treatment of inevitable, 370 

treatment, preventive, in, 367 

treatment of threatened, 367. 369 

use of placental forceps in, 372 
Accidental hemorrhage, 375, 388 

causes of, 375, 388 

dangers of, 389 

evacuation of liquor amnii in, 389 

induction of premature labor in, 545 

operation of turning in, 389 

site of placenta in, 388 

symptoms of, 376, 377, 388 

treatment of, 389 

use of Barnes's bags in, 389 

use of styptics after delivery, 389 
AccObUcheur, armamentarium of, 262 

duties of, in labor, 260 
After-pains, 693 

treatment of, 693 
Agalactia, 597 

causes of, 597 

treatment of, 597 
Ala vespertilionis, 63 
Albuminuria, in pregnancy, 226 

connection of, veith puerperal eclampsia, 
663, 664, 667 

connection of, with puerperal insanity, 
640 

detection of albumen, 659 

eifect of, in inducing premature labor, ^'61 

morbid anatomy in, connected with puer- 
peral eclampsia, 657 



Albuminuria, pressure on renal veins as a 
cause of, 658 
symptoms of, 227 
treatment of, 229, 662 
Allantois, formation of, 102 
Amnion, dropsy of, 231, 233, 579 

driipsy of, as a cause of uterine inertia, 

579 
formation of, 101 
Anaesthesia, in midwifery, 709 
in eclampsia, 663, 710 
in mania, 650, 710 
use of chloral, 660, 664, 709 
use of chloroform, 650, 664, 710 
use of ether, 709 
Angeioleucitis, connection of, with puerperal 

fever, 676 
Anorexia, in pregnancy, 217 
Anteflexion, of uterus in pregnancy, 288 
Anteversion, of uterus in pregnancy, 238 
Anus, examination by, in pregnancy, 160 
Aorta, compression of, in post-partum hemor- 
rhage, 398 
Aphasia, after labor, 708 
Appendix, 711 
Area germinativa, 101 
Areola, 151 

changes in, during pregnancy, 151 
umbilical, 152 
Arm, displacement of, in breech presentations, 
327 
dorsal displacement of, obstructing labor, 

576 
examination of. in transverse presenta- 
tions, 332, 334 
prolapse of, in transverse presentations, 

340 
presentations, see Transverse Presenta- 
tions. 
Articulations, anchylosis of foetal, obstructing 
labor, 669 
inflammation of pelvic, 234 
mobility of, during labor, 30, 35, 234 
Ascites, in foetus, obstructing labor, 568 

in pregnancy, treatment of, 231, 232 
Asphyxia, indications of, in breech presenta- 
tions, 328 
Astringents, use of, in post-partum hemor- 
rhage, 399 
Auscultntion of foetal heart, 164 
of foetal heart in twins, 164 



BALLOTTEMENT, 162 
Bandages, abdominal, application of 
274, 397, 683, 589 



720 



INDEX. 



Belladonna, use of, in rigidity of os, 554 
Bi-manual version 338, 506 

conditions favorable to, 506 

method of Braxton Hiclcs, 507 
Bi-parietal obliquity, in cranial presentations, 

279, 283, 288 (see Appendix, page 711) 
Ei-polar version, 338, 506 
Bladder, calculus in, obstructing labor, 661 

catarrh of, in pregnancy, 225 

distension of, obstructing labor, 561 

distension of, as a cause of uterine inertia, 
580 

distension of foetal, obstructing labor, 
568 

prolapse of, obstructing labor, 561 
Blasticle, 99 

Blastodermic vesicle, formation of, 100 
Blood, condition of, in pregnancy, 218 
Blunt hook, 489 

use of, in breech presentations, 326 

use of, in decapitation, 489 
Brain, embolism after labor, 708 
Breech presentations, 314 

arms passing up alongside head in, 327 

artificial delivery of head in, 329 

birth of head in, 320 

birth of shoulders in, 319 

compression of umbilical cord in, 326, 328 

craniotomy in, 525 

critical periods in, 326, 328 

diagnosis of, 316 

dorso-anterior positions in, 315 

dorso-posterior positions in, 315 

dragging on lower limbs to be avoided, 
328 

first position in, 317 

second position in, 321 

third position in, 321 

fourth position in, 322 

hydrocephalus with, 566 

indications of asphyxia of child in, 328 

management of, 325 

mechanism of labor in, 315, 317 

movement of restitution in, 326 

movement of rotation in, 317, 321, 322 

nature of assistance to be rendered in, 
326 

natural termination of, 319 

occipito-posterior termination of, 321 

operative interference in, 325 

special risks of, 319. 321, 325 

use of forceps in, 326, 328 483 

use of vectis, fillet, or blunt hook in, 326, 
488 
Brow presentations, 311 
Bulbi Vestibuli, 49 



CADAVERIC poison, connection of, with 
puerperal fever, 679, 693 
Csesarean section, see Hysterotomy. 
Caput succedaneum, 256 

in cranial presentations, 256, 286, 716 

in face presentations, 307 
Carunculge myrtiformes, 50 
Catheter, mode of introducing female, 49 
Cephalotribe, use in craniotomy, 522, 526 

use in decapitation, 494 
Childbed fever, see Puerperal Fever. 
Chloral, use of, in midwifery, 650, 666, 709 

in puerperal eclampsia, 665 

in puerperal mania, 650 



Chloroform, use of, in midwifery, 588, 650, 
663, 709 

disadvantages of, in midwifery, 709 

effect of, in blood, 709 

effect of, on nervous system, 709 

in precipitate labor, 688 

in puerperal eclampsia, 665, 831 

in puerperal mania, 650, 831 
Chlorosis, in pregnancy, 219 
Chorion, formation of, 103 
Cicatrices, obstructing labor, 557 
Circulation, disorders of, in pregnancy, 218 

in foetus, 134 
Clitoris, 49 

hypertrophy of, 63 
Coccyx, 35 

Columnse rugarum, 51 

Compound or complicated presentations, 341 
Conception, 95 

in plural pregnancy, 186 
Constipation, in newly born child, 614 

in pregnancy, 217 
Convulsions, see Puerperal Eclampsia. 
Corpus luteum, differences between unim- 
pregnated and impregnated, 81 

formation of, 79 
Cough, in pregnancy, 218 
Cramps, in labor, 266 

Crania bifida, as an obstruction to labor, 573 
Cranial planes, engagement of, at the brim, 

282 
Cranial presentations, 281 

analogy between face and, 305, 309, 311 

bi-parietal obliquity in, 279, 283, 288; see 
also Appendix, 711 

bregmato cotyloid, and fronto-cotyloid 
positions of, 295 

caput succedaneum in, 256, 285 

cause of rotation of cranium in, 284, 290 

classification of, 281 

comparative frequency of the four, 300 

complicated with other presentations, 341 

engagement of cranial planes at brim in, 
282 

examinntion of fontanelles and sutures in, 
283, 289, 293, 297 

first cranial position, 281 

second cranial position, 289 

third cranial position, 293 

fourth cranial position, 297 

head at the brim in, 282 

head at the outlet in, 288 

mechanism of labor in, 281, 293 

moulding of head in, 297 

movement of restitution in, 289, 290 

movement of rotation in, 284, 290, 294, 
298 

occipito-anterior positions in, 281 

occipito-posterior positions in, 281, 293 

occipito-frontal obliquity in, 281 

occipito-posterior positions in, artificial 
rectification of, 299 

occipito-posterior positions in, fronto an- 
terior termination of, 297 

occipito-posterior positions, mechanism of 
labor in, 294 

occipito posterior positions in, natural 
termination of, 294 

occipito-posterior positions, terminating 
in face presentations, 298 

other possible positions in, 300 

pelvic obliquity in, 288 



INDEX. 



721 



31 



the placenta. 



490 



Cranial presentations, resume of, 292 

tabular comparison of face and, 312 

theories as to causation of, 125 
Cranioclast, Braun's, 517 
Craniotomy, 511 

canting the base of the skull in, 520 

conditions favorable to, 513 

conditions -warranting, 511 

contrasted with turning, 504, 505 

cranial section by ecraseur in, 527 

extraction of the trunk in, 525 

in breech presentation, 526 

operation of turning after, 519 

perforation in, 513 

question of, in deformities of the pelvis, 
445 

stages of, 513 

use of the cephalotribe in, 522, 527 

use of the craniotomy forceps in, 517 

use of the crotchet it, 516 

use of the osteotomist in, 518 

Van Huevel's forceps-saw in, 526 
Craniotomy forceps, use in craniotomy, 517 
Craniotomy scissors, Hodge's, 515 

use in decapitation, 494 
Cranium, foetal, diameters of, 

fontanelles of, 130 

sutures of, 130 

vertex of, defined, 132 
Crede's method of deliverinf 

273 
Crotchet, 489 

history of the, 489 

objections to the use of the, 

the guarded, 490, 516 

uses of the, 491 

use in craniotomy, 516 

use in decapitation, 493 

use of double crotchet, 491 
Crowning, stage of, in labor, 258 
Crural phlebitis, see Phlegmasia Dolens. 
Cystocele, obstructing labor, 561 



DECAPITATION, 491, 527 
extraction of head in, 492 

extraction of trunk in, 492 

instruments used in, 490, 

mode of operating in, 491 

stages of operation in, 491 

use of the forceps in, 494 
Decidua, formation of, 105 

reflexa, 106 

serotina, 106 

vera, 106 

in extra-uterine pregnancy, 192 
Deformities of pelvis, 428 

aequabiliter, justo-mnjor and -minor, 436 

at the brim, 431 

at the outlet, 433 

Ctesarean section in, 446 

causes of, 429 

classification of, 429 

effects of, 437 

effect of muscular action, in causing, 436 

exaggerated sacral curvature, 434 

flattening of the sacrum in, 433 

funnel-shaped pelvis, 434 

induction of premature labor in, 543, 544 

infiintile type of pelvis, 435 

in malacosteon, 530, 432 

in rachitis, 431 
4(j 



Deformities of pelvis, in the cavity, 434 

masculine type of pelvis, 435 

obliquely distorted pelvis, 433 

osteo-sarcoma, causing, 437 

spondylolysthesis, 436 

symptoms of, 438 

the result of disease or injury, 429 

treatment in, 443 

turning or craniotomy in, 445 

use of the forceps in, 445 

use of pelvimeters in, 439 
Dentition. 620 

disorders of, 621 

management of children during, 620 

odontitis in, 622 

order of eruption of teeth in, 620 

practice of lancing the gums in, 622 

process of, a guide to proper period for 
weaning, 618, 620 

reflex effects of, on system, 620 

symptoms of, 620 
Diarrhoe;!, in pregnancy, 217 

inflammatory or dysenteric, in newly- 
born child, 614 

simple or catarrhal, in newly-born child, 
613 
Digestion, disorders of, in pregnancy., 213 
Digital examination, 154, 159 

in labor, 263, 266, 582, 589 

reflex effect of, as a cause of rupture of 
uterus, 419 
Displacements of uterus, 57, 66, 237. 243 

as a cause of uterine inertia, 579, 581 

obstructing labor, 554 
Dropsy, general, in pregnancy, 227 

of amnion, 231, 233, 580 
Dysmenorrhoea, membranous, 200 
Dyspnoea, in pregnancy, 218 



T7CLAMPSIA, see Puerperal Eclampsia. 
Vj Ecraseur, use of in craniotomy, 526 
Eetopy, obstructing labor, 572 
Elytrotomy, 539 
Embolism, of pulmonary artery, 706 

of cerebral arteries, 70S 
Embryo, definition of term, 117 

demonstration of structures of, 106 

formation of, 99 
Embryo-cell, formation of, 99 
Embryotomy, 511 

conditions warranting, 504, 512 
Erabryulcia, 525 

Encephalocele obstructing labor, 525 
Enteric fever, connection of, with puerperal 

fever, 670 
Ephemera or weed, 594 
Ergot, 583, 584 

character of contractions caused by, 584 

dangers in use of, 585 

improper use of, a cause of rupture of 
uterus, 419 

in induction of labor, 547, 584 

mode of administering, 586 

natural history of, 583 

physiological effects of, 584 

rules for use ot, in midwifery, 585 

use of, in distinguishing uterine tumors, 
584 

use of, in post-partum hemorrhage, 398 

use f f, in uterine inertia, 584 
Ether, use of, in midwifery, 709 



9,9 



INDEX. 



Erysipelas, connection of, with puerperal 

fever, 669, 671, 679 
Examination, vaginal, 154, 159, 2G3, 266, 582, 

588 
Excoriation of nipple, 605 
Excretions, disorders of, in pregnancy, 225 
Exomphalos, obstructing labor, 572 
External organs of generation, 48 
Extra-uterine pregnancy, 189 

causes of, 191 

development of membranes in, 192 

development of ovum in, 190, 191, 192 

sympathy of uterus in, 193 

symptoms of, 193 

symptoms of rupture of sac in, 195 

terminations of, 195 

treatment of, 196 

varieties of, 190 



FACE PRESENTATIONS, 304 
analogy with cranial presentations, 305, 

308, 312 
caput succedaneum in, 305, 306 
causes of, 504 
classification of, 304 
diagnosis of, 305 

distinction between obstetrical and ana- 
tomical face, 304 
first position, 306 
second position, 308 
third position, 306 
fourth position, 305 
mechanism of labor in, 305 
mento-anterior positions in. 305 
mento posterior positions in, 305, 306 
mento-posterior positions, artificial recti- 
fication of, 310 
mentoposterior positions, natural termi 

nation of 309 
movement of restitution in, 305 
movement of rotation in 305, 306 
operative interference in, 310 
tabular comparison of cranial and face 

presentations, 312 
termination of occipito -posterior cranial 

positions in, 297 
use of the straight forceps in, 480 
Fallopian tubes, 64 
Fecundation, see Conception. 
Feeding, artificial, of newly-born child, 617 
Fever, see Puerperal Fever, Milk Fever. 
Fillet, cases suitable for, 488 
history of, 488 
mode of using, 488 
in breech presentations, 326, 488 
in turning, 501 
Fissure of nipple, 602 
Foetus, attitude of, in uterus, 124 

characteristics of monthly stages in de- 
velopment of, 122 
circulation in, 133 
definition of term, 117 
dimensions of mature, 123 
diseases of, 208 

diseases of, obstructing labor, 565 
fracture of bones of, 209 
functions of, 133 

length and weight of, at birth, 123 
movements of, observed by mother and 

accoucheur, 160, 161 
nutrition in, 138 



Foetus, pulsation of heart, 164 

pulsation in twin pregnancy, 165 

respiration in, 136 

secretions in, 139 

signs of death of, 340 

spontaneous intrauterine amputation of, 
209 

un usual development of, obstructing labor, 
565 
Foetal heart, auscultation of, 161 

auscultation of, in twin pregnancy, 165 
Fontanelles, of foetal cranium, 130 

examination of, in labor, 283, 284, 291, 
293, 297 

premature closure of, obstructing labor, 
570 
Foot presentations, diagnosis of, 323 

diagnosis of foot from hand in, 323 
Fossa navicularis, 48 
Fourchette, laceration of, 258, 270 
Fractures, causing deformities of pelvis, 433 

intra-uterine, 209, 569 
Fraenulum pudendi, 48 
Forceps, 447 

application of the, 458, 460 
in dorsal position, 477 
Jenks on, 473 
to sides of pelvis, 471 

Assalini's, 483 

Chamberlen's, 448 

circumstances requiring the use of the, 
458 

conditions essential to application of, 458 

craniotomy, 516 

Davis's, 452 

Elliot's, 456 

French, 448 

Hiirper's. 483 

history of, 447 

Hodge's, 452 

the long, 467 

long, application of, 480 

long, cases suitable for, 467, 469 

long, contrasted with turning, 503, 505 

long, mode of applying, 475 

long, mode of extraction by, 480 

long, necessity of double curve in, 467 

modes of action of the, 464 

mode of applying the, 459 

mode of extracting by the, 464 

modifications of the, 482 

placental, 372 

question of single versios double curved, 
449, 451, 467, 480 

Radford's, 483 

Robertson's, 456 

Simpson's, 457 

Smith's, 455 

the short, 449 

short, cases suitable for, 451, 452 

the straight, 451, 452 

straight, reasons for preferring, 452 

straight, use of, in face presentations, 481 

Tarnier's, 480 

use of, in breech presentations, 482 

use of, in decapitation, 493 

use of, in deformities of pelvis, 444 

use of, in funis presentations, 354 

use of, in occipito posterior cranial posi- 
tions, 467 

use of, in placenta praevia, 383 

use of, in puerperal eclampsia, 66 



INDEX. 



728 



Forceps, use of, in uterine inertia, 583 

use of long and short, relative dangers 
of. 467 

Wallace's, 454. 

Ziegler's, 482 
Funis, see Umbilical Cord. 
Funis presentations, 344 

causes of, 345 

diagnosis of, 347 

postural method of treatment in, 353 

relation of, to other presentations, 345 

reposition by fingers and otherwise, 350 

rupture of membranes in, to be avoided, 
349 

special risks of, 347 

treatment in, 348 

turning in, 354 

use of forceps in, 354 
Funic souffle, 165 



GALACTORRHCEA, 597 
treatment of 597 

varieties of, 597 
Galvanism, use of, in induction of premature 
labor, 551 

use of, in post-partum hemorrhage, 398 

use of, in uterine inertia, 587 
Gastrodynia, in pregnancy, 217 
Gastro-elytrotomy, 446, i-39 
Gastrotomy, 537 

cases requiring, 537 

question of, in rupture of uterus, 427 

special dangers of, in midwifery, 537 
Gelatine of Wharton, 109 
Germinal spot, 77 

vesicle, 76 

function of, 96 
Glands, mammary, 55 

vulvo-vaginal, 52 

tubular, of uterus, 67 
Graafian vesicle, structure of, 75 
Gravid uterus, 140 

changes in os and cervix of, 155 

displacements of, 237 

involution of muscular fibres of, 142 

muscular fibres of, 141 

muscular layers of, 141 

progressive development, and anatomical 
relations of, 144 
Gums, practice of lancing the gums in denti- 
tion, 622 



HEMORRHAGE, accidental, see Accidental 
Hemorrhage, 
after delivery, preceding expulsion of 

placenta, 392 
distinction between accidental and un- 
avoidable, 375, 377, 388 
in abortion, 362, 364 
management of, in abortion, 369 
post-partum, see Post-partura Hemor- 
rhage, 
unavoidable, see Placenta Prtevia. 
Hand, examination of, in transverse presenta- 
tions, 332, 334 
diagnosis of, from foot, 323 
Hemiplegia, puerperal, 708 
Hernial tumors, obstructing labor, 563 
Hidrosis, 680, 681 
Hydatidiform moles, 203 



Hydatidiform moles, diagnosis of, 205 

pathology of, 204 

symptoms of, 205 

terminations of. 205 

treatment of, 206 
Hydrocephalus, foetal, 565 

diagnosis of, 566 

external and internal varieties of, 566 

pelvic presentations with, 566, 567 

treatment in, 567 
Hydrorrhoea, 234 
Hydrothorax, foetal, obstructing labor, 567 

perforation in, 567 
Hymen, 49 

imperforate, 54 

persistent, in labor, 556 
Hysterotomy, 528 

amount of contraction warranting, 529 

cases in which it is justifi;ible, 529 

causes of fatal result in, 536 

closure of the wound in, 535 

conditions favorable to success in, 531 

details of the operation, 531 

in deformities of the pelvis, 446 

history of, 528 

maternal mortality in. 530 

removal of the placenta in, 534 

treatment after, 535 



TCHORRH^MIA, 668 
I Icterus neonatorum, 615 
Impaction in labor, distinction between "Ar- 
rest'* and, 443 
Induction of premature labor, 541 

Barnes's process, 550 

conditions justifying, 542 

details of operation, 547 

dilatation of the os by tents, 548 

history of, 541 

in accidental or unavoidable hemorrhage. 
545 

in excessive vomiting of pregnancy, 215, 
543 

in habitual death of foetus near full time, 
542 

introduction of elastic catheter in, 548 

in impaired general health of mother, 545 

methods of, 547 

nature and scope of, 541 

in pelvic contraction, 443, 545 

plugging or distending the vagina in, £48 

rupture of the membranes in, 547 

separation of the membranes in, 548 

to obviate puerperal eclampsia, 666 

use of ergot in, 547 

use of galvanism in, 551 

vaginal or uterine injections in, 548 

viability of child in, 541 
Inert labor, see Uterine Inertia. 
Insanity, see Puerperal Insanity. 
Intellectual faculties, aberrations of, in preg- 
nancy, 235 
Intestinal deransements, influence of, on 

labor, 578, 582r5S9 
Intestines, prolapse of, in rupture of uterus, 

425 
Inversion of uterus, 405 

as a cause of post-partum hemorrhage, 
393 

causes of, 407 

chronic cases of, 411, 413 



724 



INDEX 



Inversion of uterus, diagnosis of, 400 

distinctions between, and polypus, 394, 
410 

distinctions between, and simple prolap- 
sus, 411 

dragging on cord as a caupe of, 407 

in unimpregnated state, 406 

irregular contraction of uterus as a cause 
of, 4 07 

management of adherent placenta in, 411 

mechanism of the displacement in, 409 

paralysis of the fundus, as a cause of, 409 

removal by ecraseur in, 415 

successive stages of, 4' 6 

sustained elastic pressure in, 414 

symptoms of, 409 

Thomas's operation for the reduction of, 
415 

treatment in, 411 

treatment in chronic cases of, 413 

uterine inertia as a cause of, 409, 413 



KNEE presentations, diagnosis of, 323 
Kyesteine, 149 



LABIA MAJORA, 49 
minora, 49 

hypertrophy of, 53, 556 
Labor, 244 

action of voluntary muscles in, 248, 257, 

265 
caput succedaneum in, 256 
causes of, 244 

cramps in thighs during, 266 
crowning, stage of, in, 258 
digital examination in, 261, 263, 266, 

582, 589 
duties of accoucheur in, 261 
effect of emotional causes on, 247 
first stage of labor, 249 
first stage, duration of, 255 
first stage, management of, 264 
first stage, rigor on termination of, 254 
first stage, termination of, 254 
functions of liquor amnii in, 253 
inert, see Uterine Inertia, 
influence of intestinal derangements on, 

578, 582, 589 
insanity of, see Puerperal Insanity, 
irregularities in the progress of, 581 
management of, 260 
mechanism of, 275 
mechanism of dilatation of os and cervix 

in, 252 
mobility of articulations during, 30, 35, 

284 
natural lubrication of vagina in, 251 
obstructions to, see Obstructions to Labor, 
oedema of anterior lip of os in, 257, 267 
pains of, 250, 254, 255, 258 
perineum, dilatation of, 257 
perineum, laceration of, in, 258, 270 
perineum, rigidity of, in, 271 
perineum, support of, in, 268 
peristaltic action of uterus in, 247 
persistent hymen in, 556 
precipitate, se<i Precipitate Labor, 
preliminary arrangements in, 260 
preparation of bed for, 265 
preparatory stage of, 249 



Labor, reflex function of spinal cord in, 247 

retention of urine in, 266 

rigidity of os in, 255, 268, 553 

rupture of membranes in, 253, 254, 267 

second stage of labor, 256 

second stage, management of, 265 

second stage, termination of, 258 

"show" on termination of first stage, 254 

stages of, 249 

third stage of, 258 

third stage, management of, 272 

use of stethoscope in, 268 
Labor pains, 250 

character of, in first stage, 254 

character of, in second stage, 256 

character of, in third stage, 258 

difference between true and false, 252 

effect on maternal pulse, 251 

effect on uterine souffle, 252 

false, treatment of, 261 
Lactation, 594 

agalactia, 597 

disorders of, 600 

duration of, 599 

galactorrhoea, 597 

influence of menstruation on, 599 

influence of pregnancy on, 600 

insanity of, see Puerperal Insanity. 

management of, 598 

milk too rich, 598 

milk too watery, 597 

pain in mammae during, 595 

prejudicial effects of overfeeding in, 598 
Laparotomy, 427, 537 
Laparo-Elytrotomy, 539 
Leucorrhoea, 230 
Liebig's food for infants, 617 
Ligaments, of ovaries, 64 

of pelvis, 38 

of uterus, broad, 61 

of uterus, posterior, 65 

of uterus, round, 63 

vesicouterine, 64 
Ligature of the cord, in newly-born child, 271, 

607 
Liquor amnii, 105 

evacuation of, in accidental hemorrhage, 
389 

evacuation of, in placenta prsevia, 381, 
387 

functions of, in labor, 252 

management of, see Membranes. 
Lochia, 591 

management of the, 592 

nature and source of the. 591 
Lungs, puerperal affections of, 706 



MALACOSTEON, 429, 430 
contrasted with rachitis, 430 
Mammse, application of child to, at fixed in- 
tervals, 595, 610 
changes in, during pregnancy, 149 
early application of child to, 274, 397, 

593, 594, 610 
inflammation and abscess of, 600 
management of, after delivery, 594 
pain in, during nursing, 596 
secretion of milk in, 150, 594 
Mammary glands, 55 
Mania, see Puerperal Insanity. 
Meatus urinarius, 48 



INDEX 



725 



Mechanism of dilatation of os and cervix in 
labor, 253 

of expulsion of placenta, 258 

of labor, 275 

of labor in breech presentations, 314, 316 

of labor in cranial presentations, 281, 
293 

of labor in face presentations, 305 
Melancholia, see Puerperal Insanity. 
Membranes, artificial rupture of, in labor, 267 

artificial separation of, in induction of 
labor, 548 

development of, in extra-uterine preg- 
nancy, 192 

disposition of, in twin pregnancy, 186 

management of, in funis presentations, 
350 

management of, in puerperal eclampsia, 
666 

management of, in transverse presenta- 
tions, 331 

premature rupture of, as a cause of pre- 
cipitate labor, 387 

premature rupture of, as a cause of ute- 
rine inertia, 579 

rupture of, in induction of labor, 547 

separation of, in induction of labor, 548 

spontaneous rupture of, in labor, 254 

unusual thickness and resistance of, ob- 
structing labor, 576 
Menstruation, 85 

analogy with "rut," 85 

amount of discharge during, 89 

cause of, 94 

character of discharge in, 89 

conditions influencing age at which first 
occurrence of, 86 

delayed, distinguished from abortion, 362 

duration of, 89 

duration of epoch of, 94 

influence of lactation on, 600 

irregularities in, 93 

phenomena attending first occurrence of, 
86 

source of discharge in, 90 

suppression of, in pregnancy, 146 
Mesoblast, 102 

Metritis, see Puerperal Metritis. 
Midwifery, defined, 33 

history of, 17 
Milk, escape of, from mammae, 596 

estimation of quality of, 597, 599 

period for permitting other food than, 617 

secretion of, see Lactation. 

substitutes for breast- milk, 615, 617 

treatment when too rich or too watery, 599 
Milk-fever, 594 
Miscarriage, see Abortion. 
Missed labor, 208 
Moles, 199 

false, 199 

fleshy, 201 

hydatidiform, see Hydatidiform Moles. 

true, 200 
Mons veneris, 48 
Monstrosities, 210, 572 

acephalic, 572 

aneneephalic, 572 

ectopy, 573 

examphalos, 573 

fusion of twins, 573 

by inclusion, 187, 574 



Monstrosities, obstructing labor, 573 

the Siamese twins, 574 
Moral faculties, aberrations of, in pregnancy, 

235 
Morbus coxarius, causing deformities of ])el- 

vis, 438 
Morninof sickness, of pregnancy, 148, 213, 

357, 542 



NERVOUS SYSTEM, disorders of, in preg- 
nancy, 235 
Newly-born child, 607 

administration of laxatives to the, 609, 

613 
application of, to mammae at fixed inter- 
vals, 595, 609 
artificial feeding of the, 615 
cleanliness of, 609 
clothing of, 608 

congenital malformations of, 612 
desirability of mother nursing, 609 
diet and regimen of hired nurses of, 611 
difficulties of, in sucking, 513 
early application of, to mammae, 275, 397, 

593, 594, 609 
food of, before mammary secretion es- 
tablished, 609 
habitual constipation in, 614 
harelip in, 613 

imperforate anus or urethra, in the, 613 
inflammatory or dysenteric diarrhaea, in 

the, 613 
management of the, 607 
management of the bowels in the, 610, 

613 
management of the cord in the, 607 
management of restlessness in the, 609 
necessity of air and light to the, 609 
nurse to be procured if artificial feeding 

fail, 616 
period for permitting other food than 

milk, 617 
premature, must be reared at the breast, 

616 
retention of urine in the, 613 
selection of hired nurses for the, 610 
simple or catarrhal diarrhoea in the, 613 
thrush in the, 615 
Nipple, changes in during pregnancy, 150 

excoriation and fissure of, 605 
Nursing, application of child to mammEe at 

fixed intervals, 595, 610 
artificial feeding of the child, 616 
desirability of rearing child at breast, 

610, 616 
early application of child to the breast, 

275, 397, 593, 594. 619 
food of child before mammary secretion 

established, 610 
Liebig's food for infants, 617 
nursing bottles, 616 
premature child must be reared at breast, 

616 
substitutes for breast milk, 616 
Nymphae, see Labia Minora. 



OBSTRUCTIONS to labor, 553 
abnormal conditions of vulva and vaginf 

556 
anchylosis of foetal articulations, 569 



726 



INDEX 



Obstructions to labor, ascites of foetus, 568 
cicatrices from sloughing, 557 
coiling of cord round child, 576 
cystocele, 661 

distension of maternal bladder, 561 
distension of foetal bladder, 569 
dorsal displacement of the arm, 576 
ectopy, 572 

effects of uterine displacement, 555 
encephalocele and spina bifida, 568 
exoraphalos, 572 

fecal accumulation in rectum, 561 
fibrous, fatty, or encysted growths, 563 
gaseous distension from putrefaction, 569 
hernial tumors, 563 
hydrocephalus of foetus, 565 
hydrothorax of foetus, 569 
hymen, persistent, 556 
hypertrophy of anterior lip and cervix, 

267, 554 
hypertrophy of nymphae and preputium 

clitoridis, 557 
intra-uterine fracture, 209, 569 
locked twins, 571 

malignant disease of the canal, 564 
monstrosities, 572 
occlusion of OS, 653 
ovarian tumors, 669 
plural pregnancy, 570 
polypoid tumors of uterus, 558 
premature closure of sutures and fonta- 

nelles, 569 
prolapse of the bladder, 561 
rigidity of the os. 256, 267, 553 
rigidity of the perineum, 271, 556 
seirrhus of rectum and rectocele, 561 
shortness of cord, 575 
spasmodic contraction of the cervix, 554 
tumors; renal, hepatic, &c., 669 
unusual development of foetus, 565 
unusual thickness and resistance of the 

membranes, 576 
urinary calculus, 561 
vaginal thrombus, 557 

Occipito-Anterior Cranial Positions, mechan- 
ism of labor in, 281 

Oecipito-Frontal Obliquity, in cranial pre- 
sentations, 281 

Occipito-Posterior Cranial Positions, artificial 
rectification of, 299 
bregmatocotyloid termination in, 296 
frontocotyloid termination in, 296 
mechanism of labor in, 294 
natural termination in, 294, 296 
terminations of in face presentation, 297 

Occlusion of Os Uteri, obstructing labor, 
653 

Odontitis, 622 

Oraphalo-mesenteric vessels, 102 

Organs of generation, external, 48 
internal, 57 

Os uteri, abscess and thrombus of lips in la- 
bor, 566 
changes in os and cervix during preg- 
nancy, 155 
condition and appearance of unimpreg- 

nated, 60 
detection of os by speculum, 554 
hypertrophy of anterior lip, in labor, 267, 

555 
mechanism of dilatation of os uteri in 
labor, 253 



Os uteri, mode of applying leeches to cervix 
and OS, 703 

occlusion of, in labor, 563 

oedema of anterior lip in labor, 256, 267 

relation of os uteri to pelvic walls in 
pregnancy, 159 
Osteomalacia, see Malacosteon. 
Osteosarcoma, causing deformities of pelvis, 

437 
Osteotomist, use of the, in craniotomy, 518 
Ovaries, anatomy of, 74 

ligaments of, 65 
Ovarian pregnancy, 189 

Ovarian tumors, diagnosis from pregnancy, 
153 

obstructing labor, 659 
Ovulation, phenomena of, 78 
Ovum, anatomy of, 76 

contact of, with spermatozoa, 97 

development of, 98 

development of in extra-uterine preg- 
nancy, 189, 191 

haemorrhagic discharges from, 200 

premature expulsion of, 356 
Oxytocics, use of, in uterine inertia, 683 



PAIN, abdominal, in pregnancy, 236 
of labor, see Labor Pains. 

mammary, during nursing, 596 

uterine, in pregnancy, 236 
Palpation, abdominal, in pregnancy, 153, 162 
Parametritis, 696 
Parovarium, 66 
Parturient canal, axis of, 41 
Parturition, cause of comparative difficulty in 
human species, 26 

forces which effect, 246 

in the primates, 26 

in the various races, 26 

mechanism of, 275 

post-mortem, 246 
Pelvic cellulitis, 698 

abscess in, treatment of, 706 

anatomy of pelvic cellular tissue with re- 
gard to, 699 

diagnosis between pelvi-peritonitis and 
cellulitis, 700 

mode of detecting pus in, 702 

treatment in, 702 
Pelvic measurements, 45 

conjugate, warranting the different ope- 
rations, 540 
Pelvic Presentations, see Breech Presenta- 
tions. 

comparative frequency of, 316 

special risks of, 320, 323, 326 
Pelvimetry, instrumental and manual, 438 
Pelvi-peritonitis, 671, 695, 696 

abscess in, 701, 704 

Bernutz on, 698 

counter-irritation in, 704 

diagnosis from pelvic cellulitis, 700 

leeching in, 703 

mode of detecting pus in, 702 

mode of diagnosis in, 697 

treatment of, 702 

use of iodine in, 704 

use of mercury in, 704 
Pelvis, 33 

sequabiliter justo-major and -minor, 436 

angles of, 41, 45 



INDEX 



727 



Pelvis, axis of the true, 41 
bones of, 33 
brim of, 42 
cavity of, 43 

comparative anatomy of, 23 
deformities of, see Deformities of Pelvis, 
development of, 45 
diameters of, 42, 44 

difference between male and female, 36 
floor of, 47 
funnel-shaped, 434 
human, a curved canal, 29 
inclination of, 40 
infantile type of, 435 
inflammation of articulations of, 235 
ligaments and nrticuhitions of. 38 
malacosteon, 432 
masculine type of, 434 
mobility of articulations during labor, 30, 

35, 235 
obliquely distorted, 432 
outlet of, 44 
rachitic, 432 

soft structures connected with, 46 
" true" and "false," 35 
Perforator, use of, in craniotomy, 514 

use of, in decapitation, 493 
Perimetritis, 696, 697 
Perineum, 48 

dilatation of, in labor, 257 
laceration of, 270 

management of, in labor, 267, 270, 553 
treatment in threatened laceration, 270 
treatment of rigidity in labor, 270, 553 
Peritonitis, see Puerperal Peritonitis and 

Pelvi-Peritonitis. 
Peri-uterine hnematocele, 706 
Peri-uterine phlegmon, see Pelvic Cellulitis. 
Phlebitis, see Puerperal Phlebitis. 

crural, see Phlegmasia Dolens. 
Phlegmasia dolens, 624 
after effects of, 627 
antiseptic remedies in, 637 
causes of, 624 

causes of protracted convalescence in, 637 
causes unconnected with recent delivery, 

624, 634 
characteristic appearance of swelling in, 

626 
connection of, "with hemorrhagic cases, 

624 
connection of, with puerperal fever, 676 
connection of, with pleuropneumonia 
and embolism of pulmonary artery, 706 
eflBcacy of blistering in, 636 
morbid anatomy of, 628 
most common in left leg, 624 
most common in pluriparae, 624 
nomenclature of, 624 
pathology of, 628, 631 
premonitory signs of, 625 
question of blood-letting in, 635 
question of contagiousness, 636 
symptoms of, 625 

tendency of, to attack other leg, 624 
terminations of, 627 
treatment of, 635 
use of bandages in, 636 
usual time of occurrence of, 624 
Phosphatic diathesis, in pregnancy, 37 
Phrenitis, to be distinguished from puerperal 
mania, 642 



Placenta, 110 

abnormalities of, 391 

adherent, extraction of, 273 

adherent, management of, in inversion of 
uterus, 411 

anatomy of, 110 

apoplexy of, 207, 359 

artificial extraction of, in placenta praevia, 
383 

artificial separation of, in placenta prsevia, 
385 

atrophy of, 207 

calcareous degeneration of, 207 

causes and treatment of retained, 390 

causes of true adhesion of, 390 

Crede's method of delivering, 273 

diseases of, 207, 359 

diseases of, causing abortion, 359 

disposition of, in twin pregnancy, 186 

dropsy of, 207 

expulsion of, 258 

expulsion of, in abortion, 366 

extraction of, 273 

extraction of, in rupture of uterus, 425 

fatty degeneration of, 207 

functions of, 1 13 

hypertrophy of, 207 

intiammation of, 207 

management of, in abortion, 371 

mechanism in expulsion of, 258 

removal of, in hysterotomy, 534 

results of disease in, 207, 359 

retention of, 273, 391 

retention of, in abortion, 366 

encysted, 391 

site of, in accidental hemorrhage, 388 

spontaneous expulsion of, in placenta 
praevia, 378, 383 
Placental forceps, use of, 372 
Placental polypus, 373 
Placenta Praevia, 375 

artificial extraction of placenta in, 383 

artificial separation of placenta in, 385 

causes of, 376 

evacuation of liquor amnii in, 381 

idea of ancients as to nature of, 375 

natural termination of complete and par 
tial. 378, 383 

operation of turning in, 381, 387 

proclivity to recurrence of, 378 

spontaneous expulsion of placenta in, 
383 

symptoms and signs of, 376 

treatment of, 379 

treatment, resume of, 387 

use of Barnes's bags in, 382, 387 

use of forceps in, 383 

use of styptics after delivery in, 390 

use of vaginal plug or tampon in, 380, 
382 

varieties of complete and partial, 375 
Placental presentation, see Placenta Prasvia. 
Plethora in pregnancy, 221 
Pleuro-pneumonia, puerperal, 706 
Plural pregnancy, 185 

as an obstruction to labor, 570 

duration of, 188 

mode of impregnation in, 186 
Pneumonia, puerperal, 706 

and phlegmasic dolens, 625 
Polypus, fibroid, of uterus, distinctions from 
inversion, 394, 410 



728 



INDEX. 



Polypus, obstructing labor, 558 
Postpartum hemorrhage, 390, 392 

astringents in, 399 

causes of, 392 

compression of aorta in, 399 

effects of rest and position in, 401 

fibroid tumors of uterus as a cause of, 393 

inversion of uterus as a cause of, 393 

manual pressure on uterus in, 397 

passage of hand into uterus in, 397 

plugging in, 398 

reflex effect of cold in, 397 

secondary, 401 

symptoms of, 394 

tendency to reaction in, 402 

transfusion in, see Transfusion. 

treatment of, 396 

use of ergot, 397, 398 

use of galvanism, 398 

use of Gariel's air pessary, 398 

use of iodine, 401 

use of stimulants and opium, 401 

ues of styptics, 399 

uterine inertia as a cause of, 391, 393 
Post-partum inflammations, connection of, 
with puerperal fever, 671, 683 ; see also 
Puerperal Peritonitis, Pelvi peritonitis, 
Perimetritis. 
Precipitate labor, 587 

causes of, 587 

dangers of, 588 

from deficiency of resistance, 587 

influence of premature rupture of mem- 
branes on, 587 

influence of temperament on, 586 

treatment in, 688 

use of opium and chloroform in, 588 
Pregnancy, 140 

abdominal, 191 

abdominal pain in, 236 

abdominal palpation in, 153, 162 

albuminuria in, see Albuminuria. 

anteflexion and anteversion of uterus in, 
238 

appearance of abdomen during, 152 

ascites in, 231 

ballottement in, 162 

cases of protracted, 174 

catarrh of bladder in, 226 

changes in mammae during, 149 

changes in os and cervix during, 155 

changes of umbilicus in, 151 

chiinges in urine during, 148 

chlorosis in, 218 

color of vagina in, 53, 154 

constipation in, 217 

diarrhoea in, 217 

differential diagnosis of abdominal tumors 
from, 153 

digestive disorders in, 147, 211, 357, 543 

digital examination in, 153 

discoloration of skin in, 151 

diseases of, 211 

disorders of circulatory system in, 218 

disorders of locomotion in, 234 

disorders of the nervous system in, 225 

disorders of respiration in, 218 

disorders of secretion and excretion in, 

225 
duration of, 172 

duration of, in cows and mares, 172 
effects of, on the system, 653 



Pregnancy, examination, peranum, in, 160 

extra-uterine, see Extra-Uterine Preg- 
nancy. 

flattening of abdomen in, 152 

foetal pulsation in, 164 

funic souffle in, 165 

influence of lactation on, 600 

insanity of, 638 

mode of calculating duration of, 177 

morning sicliness of, 148, 212, 357, 543 

normal effect of, on the mind, 638 

ovarian, 189 

plethora in, 221 

plural, see Plural Pregnancy. 

quickening in, 160 

salivation in, 148, 225 

signs of, 145 

signs of, certain, 170 

suppression of the catamenia in, 146 

table showing signs of, at various epochs, 
188 

treatment of digestive disorders, 214, 
542 

tubal, 190 

uterine pain in, 236 

uterine souffle in, 166 

vaginal examination in, 154, 159 

vaginal pulse in, 154 
Premature labor, 373 

causes of, 358, 373 

definition of term, 356 

effect of albuminuria in causing, 661 

induction of, see Induction of Premature 
Labor. 

influence of emotional causes on, 360 

symptoms of, 374 

treatment of, 374 
Presentation, compound or complicated, 341 

definition of term, 125, 279, 285 

of the arm or shoulder, see Transverse 
Presentations. 

of the breech, see Breech Presentations. 

of the brow, 314 

of the face, see Face Presentations. 

of the foot, 323 

of the funis, see Funis Presentations. 

of the knee, 323 

of the pelvis, see Pelvic Presentations. 

of the placenta, see Placenta Prsevia. 

natural and faulty, 280 

of the vertex, see Cranial Presentations. 

relative frequency of various presenta- 
tions, 280 
Prolapse of uterus, distinctions between in- 
version and prolapse, 411 

in pregnancy, 237 
Pubiotomy, 539 
Puerperal angeioleucitis, 676 
Puerperal eclampsia, 652 

Barnes's theory of causation of, 653 

connection of, with acute Bright's dis- 
ease, 652, 653, 657 

definition of, 652 

detection of albumen in urine in, 659 

distinction of, from other forms of eclamp- 
sia, 652, 657 

duration of tonic and clonic convulsions, 
and of coma, in, 656 

formation of carbonate of ammonia in 
blood in, 657 

maternal and foetal mortality in, 660 

morbid anatomy of, 659 



INDEX. 



729 



Puerperal eclampsia, mortality, with treat- 
ment by bleeding and anaesthetics, 665 

pathology of, 657 

premonitory symptoms and signs of, 654 

pressure on renal veins as a cause of albu- 
minuria in, 658 

question of blood-letting in, 665 

question of induction of labor to obviate, 
663 

reflex sensibility in the causation of, 
660 

rupture of the membranes in, 666 

symptoms of, 654 

theories as to connection with albumi- 
nuria, 657 

treatment after delivery in, 666 

treatment of, during fit, and in different 
epochs, 662 

treatment, obstetrical, 665 

treatment, prophylactic, 662 

use of anaesthetic agents in, 663, 710 

use of the forceps in, 666 

uterine contractions as a cause of, 659 
Puerperal fever, 667 

affections allied to, 671 

causes of, 668, 6C9, 677 

condition of blood in malignant form of, 
685 

connection of, with angeioleucitis, 676 

connection of, with cadaveric poison, 679, 
687 

connection of, with enteric fever, 670 

connection of, with erysipelas, 669 

connection of, with metritis, 673 

connection of, with peculiarities of puer- 
peral state, 669, 678 

connection of, with peritonitis, 671, 678, 
682 

connection of.with phlegmasia dolens, 676 

connection of, with post-partum inflam- 
mations, 671, 682 

connection of, with puerperal vaginitis, 675 

connection of, with scarlatina, 669 

connection of, with measles and diphthe- 
ria, 670 

connection of, with septic aborption, 667, 
678, 683 

connection of, with typhus fever, 671 

connection of, with uterine phlebitis, 674, 
684 

connection of, with variola, 670 

different forms of, 678, 682 

history of epidemics of, 880 

morbid anatomy of, 683 

nomenclature and classification of, 668, 
671 

question of contagiousness of, 677, 687, 
693 

question of specific nature of, 668 

question of tapping in, 693 

reasons for retaining term of, 667 

symptoms of, 681 

treatment of, 687 

treatment by bloodletting in, 685, 687, 689 

treatment by emetics in, 690 

treatment, prophylactic in, 686, 693 

treatment by purgatives in, 689, 690 

treatment by stimulants and tonics in, 
688, 691 

treatment, topical, in, 693 

use of antiseptics in, 693 

use of blisters in, 691, 692 
47 



Puerperal fever, use of cnlomel in, 692 

use of cold baths in, 692 

use of iodine in, 692 

use of the sulphites in, 692 

use of turpentine in, 692 

variations in type of, 680, 681 , 684, 686, 688 
Puerperal phlebitis, 674 

connection of, with puerperal fever, 674 

morbid anatomy of, contrasted with puer- 
peral fever {see, also, Phlegmasia Do- 
lens), 683 
Puerperal insanity, 638 

causes of, 639 

connection of, with albuminuria, 640, 647 

during labor, 639 

during lactation, 639 

during pregnancy, 639 

hereditary predisposition in, 640 

influence of age on, 640 

most frequent in primipaiae, 640 

nomenclature of, 638 

normal effect of pregnancy on the mind, 
638 

pathological theories of, 640 

prognosis of, 645, 647 

recurrence of attack of, 651 

relative frequency of, 639 

seclusion and restraint in, 650 

suicidal impulse in, 651 

treatment of, 647 

true, 656 
Puerperal mania, 642 

essentially a disease of exhaustion, 642 

phrenitis to be distinguished from, 642 

prognosis of, 645, 647 

significance of a rapid pulse in, 644 

symptoms of, 643 

treatment of, 647 

treatment of, preventive, 647 
Puerperal melancholia, 645 

prognosis of, 646 

symptoms of, 646 

treatment of, 651 
Puerperal metritis, 673 

morbid anatomy of, contrasted with puer- 
peral fever {see, also, Peri- metritis and 
Pelvi-peritonitis), 683 
Puerperal peritonitis, 671 

connection of, with acute tympanites, 672 

connection of, with puerperal fever, 671, 
672 

distinction from acute tympanites, 674 

false peritonitis, 674 

morbid anatomy of, contrasted with puer- 
peral fever, 683 

symptoms of ordinary forms, 671 

symptoms of severe form, 672 
Puerperal state, connection of, with puerperal 
fever, 669, 679 

management of the, 275, 590 

relation of the, to disease, 623 

sudden death in, 706 
Puerperal pyaemia and septicaemia, 671, 677 
Puerperal vaginitis, connection of, with puer- 
peral fever, 675 
Pulmonary artery, thrombosis and embolism 

of, various forms, 706 
Pyrosis, in pregnancy, 217 



Q 



UICKENING, 160. 179 



730 



INDEX. 



RACHITIS, 429 
cotitrasted with malaeosteon 430 
Rectocele, obstructing labor, 561 
Repercussion, see Ballottement. 
Respiration, disorders of, in pregnancy, 218 
Restitution, movenaent of, in cranial presen- 
tations, 292 
Retroflection, of uterus in pregnancy, 239 
Retroversion, of uterus in pregnancy, 239 
Rigidity of os uteri, 256, 26'^, 553 

causes of, 563 

from disease, 654 

functional, 553 

occlusion of os, 553 

trentment of, from disense, 654 

treatment of simple or functional, 554 
Rigidity of perineum, 271, 553 

treatment in, 554 
Rigor, in labor, 254 

Rotation, movement of, in breech presenta- 
tions, 317, 321, 322 
movement of, in cranial presenta- 
tions, 284, 291 
movement of, in face presentations, 
305,306 
Rupture of uterine ligaments, 423 
Rupture of sac in extra-uterine pregnancy, 195 
Rupture of uterus, 416 

atrophy of uterus as a cause of, 420 

causes of, 419 

during pregnancy, 416 

extraction of child in, 424 

extraction of placenta in, 424 

improper use of ergot as a cause of, 420 

premonitory symptoms of, 421 

prolapse of intestine in, 425 

question of gastrotomy in, 427 

question of turning in, 425 

reflex effect of digital examination as a 
cause of, 420 

relation of, to duration of labor, 419 

relative frequency of, in primiparae, 418 

rigidity of os as a cause of, 420 

signs of, 421 

sites of laceration in, 418 

treatment in, 423 

treatment during pregnancy, 427 

varieties of, 417 
Rupture of vagina, 423 
Rut, analogy with Menstruation, 85 



SACRUM, 34 
exaggerated curvature of, 434 
flattening of the sacrum, 433 
Salivation, in pregnancy, 148, 225 
Scarlatina, connection of, with puerperal 

fever, 669 
Scirrhus, of rectum, obstructing labor, 560 
Scybala, as a cause of uterine inertia, 580 

obstructing labor, 561 
Secre'ions, disorders of, in pregnancy, 235 
Semen, composition of, 95 
Senses, special, affections of, in pregnancy, 

235 
Septic absorption, connection of, with puer- 
peral fever, 667, 678, 683 
Septicaemia, puerperal, 667 
Shoulder presentations, see Transverse Pre- 
sentations, 
comparative frequency of, 331 
Show, in labor, 254 



Skin, discoloration of, in pregnancy, 151 
Souffle, funic, 166 

uterine, 166 
Spermatozoa, contact of ovum with, 97 

development of, 95 
Spinal cord, reflex function of, in labor, 246 
Spondylolysthesis, 246 

Spina bifida, as an obstruction to labor, 568 
Spontaneous evolution, in transverse present- 
ations, 335, 341 
Spontaneous expulsion, in transverse present- 
ations, 335 
Stethoscope, use of, in labor, 268 
Stimulants, use of, in labor, 582 
Strychnia, use of, in uterine inertia, 587 
Styptics, use of, in post-partum hemorrhage, 

399 
Sucking, difficulties of the newly-born child 

in, 612 
Sudden death, in puerperal state, 706 
Superfecundation, 180, 195 
Superfoetation, 180 

relation of, to twins, 183 
Suspended animation, treatment of, in newly- 
born infant, 272 
Sutures, of foetal cranium, 130 

examination of, in labor, 283, 290, 293, 

297 
premature closure of, obstructing labor, 
570 • 
Symphysiotomy, 538 

history and nature of, 638 
results of, 638 



TEETHING, see Dentition. 
Thrombosis, of pulmonary artery {see 
also Phlegmasia Dolens), 706 
Thrombus, of lips of os uteri, 555 

of the vagina, 222 
Thrush, in the newly-born child, 615 
Tumors, foetal, obstructing labor, 669 

maternal, obstructing labor, 557, 659 
Transfusion, 402 

"immediate" and "mediate" processes 
of, 403 
Transverse presentations, 330 

causes of, 330 

cephalic version in, 338 

combined version in, 338 

comparative frequency of, 331 

diagnosis of positions in, 332 

dorso-anterior and dorso-posterior posi- 
tions in, 333 

examination of arm in, 332, 334 

methods of operative interference in, 338 

podalic version in, 339 

premature rupture of membranes in, to 
be avoided, 332 

probable course of, in unaided cases, 
334 

prolapse of arm in, 339 

signs of, before and during labor, 331 

spontaneous expulsion in, 335 

spontaneous evolution in, 335, 341 

treatment of, 338 
Triplets, 188 

Tubal pregnancy, 189, 190 
Turning, 496 

bi-polar version, 339, 606 

cephalic version, 503 

choice of hands in, 497 



INDEX. 



731 



Turning, circumstances rendering operation 
of, difficult, 497 
conditions requiring, andfavorable'to, 496 
contrasted with craniotomy, 504, 505 
contrasted with the use of the lung for- 
ceps, 503, 505 
history of, 495 

in accidental hemorrhage, 389 
in deformities of pelvis, 444 
in funis presentations, 355 
in placenta praevia, 381, 387 
in rupture of uterus, 425 
management of the case after, 502 
measurements admitting of, 504 
method of Braxton Hicks, 508 
method of Robert Lee, 506, 507 
method of Wigand, 506 
mode of operating in, 496 
operation of, after craniotomy, 519 
pelvic version, 503 ■ 
podalic version, 496 
position of the child after, 502 
question of bringing down one leg or two 

in, 499 
question of, in contracted pelvis, 503 
question of, in funis presentations, 355 
special difficulties of, in deformities of 

pelvis, 505 
use of the noose or fillet in, 501 ; 

various methods of, 495 : 

Twin pregnancy, diagnosis of, 187 

disposition of membranes and placenta 
in, 186 I 

relation of, to superfoetation, 186, 188 j 
varieties of, 186, 187 
Twins, fusion of, 572 j 

locked, obstructing labor, 571 ■ 

the Siamese, 574 j 

Tympanites, acute, distinction from puerperal t 
peritonitis, 673 ! 

symptoms of, 673 ' 

Typhus fever, connection of, with puerperal 
fever, 671, 678 



UMBILICAL CORD, anatomy of, 108 
coiling of, round foetus, obstructing labor, 

575 
compression of, in breech presentations, 

326, 327 ; 

diseases of, 208, 359 | 

diseases of, causing abortion, 359 | 

dragging on, a cause of Inversion of j 

uterus, 407 
knots in, 109, 359 I 

ligature of, 272 

ligature of, in twin pregnancy, 272 
management of the, after birth, 272 
presentation of the, see Funis Presenta- 
tions, 
shortness of, obstructing labor, 575 
souffle, funic, 166 
vessels of, 103 
Umbilical vesicle, 101 
Umbilicus, changes of, in pregnancy, 151 
Unavoidable hemorrhage, see Placenta Preevia. 
Unimpregnated uterus, 57 
anatomy of, 57 
axis of, 58 

condition and appearance of os in, 60 
difference between impregnated and un- 
impregnated, 60, 82 



Unimpregnated uterus, displacements of, 66 

ligaments of, 62 
Urachus, 103 
Urethra, 49 

imperforate, in child, 619 
Urine, changes in, during pregnancy, 149 
detection of albuminuria by examination 

of, 658 
retention of, after delivery, 591 
retention of, in labor, 266 
retention of, in newly-born child, 613 
Urinary calculus, obstructing labor, 561 
Uterine appendages, inflammation of, 695, 

696 
Uterine phlebitis, see Puerperal Phlebitis. 
Uterine inertia, 577 

as a cause of inversion of uterus, 407, 413 
as a cause of postpartum hemorrhage, 

391, 392 
causes of, 578 

distended bladder or rectum in, 582 
influence of age and frequent pregnancy 

on, 579 
influence of climate and season, 579 
influence of emotional causes, 579 
influence of excessive uterine distension, 

580, 581 
influence of irregular uterine action, 580 
influence of temperament, 579 
influence of uterine displacements, 579, 

581 
morbid conditions of the uterus in, 530, 

581 
treatment in, 581 
use of ergot in, 583 
use of the forceps in, 583, 586 
use of galvanism in, 398 
Wigand's and Scanzoni's classifications 

of, 580 
lymphatics, inflammation of, associated 
with puerperal fever, 676 
Uterine pain, in pregnancy, 235 
Uterine souffle, 166 

effect of labor pains on, 252 
Uterine tumors, diagnosis of, from pregnancy, 
152 
use of ergot in distinguishing, 584 
Uterus, 57 

abnormal development of, 71 

atrophy of, as a cause of rupture of, 420 

attitude of foetus in, 125 

bloodvessels of, 70 

case of impregnation in double, 183 

difference between unimpregnated and 

impregnated, 61, 81 
displacements of, 58, 65, 237, 243 
displacements of, as a cause of inertia, 

578, 581 
displacements of, obstructing labor, 555 
fibrinous and hemorrhagic casts of, 199 
fibroid tumors of, causing post partum 

hemorrhage, 393 
gravid, see Gravid Uterus, 
inversion of, see Inversion of Uterus, 
irregular action of, causing inertia, 580 
ligaments of, 62, 65 
lymphatics and nerves of, 71 
malformations of, 71 
morbid conditions of, causing inertia, 

580, 581 
nervi-motor functions of, in labor, 246 
peristaltic action of, in labor, 246 



732 



INDEX. 



Uterus, rupture, see Rupture of Uterus, 
spontaneous expulsion of, 423 
sympathy of, in extra uterine pregnancy, 

193 
tumors of, obstructing labor, 657 
unimpregnated, see Unimpregnated Ute- 
rus. 



VAGINA, 62 
abnormal conditions of, obstructing labor, 

566 
change in color of, during pregnancy, 53, 
164 
Vagina, double, 54 

examination by, in pregnancy, 53, 164, 

169 
laceration of, 422 

natural lubrication of, in labor, 251 
plugging of, in abortion, 370 
plugging of, in placenta prasvia, 380, 382 
plugging of, in post-partum hemorrhage, 

398 
the so-called Caesarean section through, 

637 
thrombus of, 222, 667 
Vaginal pulse, in pregnancy, 164 
Vaginismus, 54 
Vaginitis, granulosa, 231 

puerperalis, 675 
Varicose veins, in pregnancy, 221 
Variola, connection of, with puerperal fever, 
670 



i Vectis, 485 

cases suitable for, 487 
history of, 485 
I mode of using, 486 

objections to use of, 486 
use of, in breech presentations, 326 
Veins, varicose, in pregnancy, 221 
I inflammation of, see Phlebitis, Phlegma- 

sia Dolens, &c. 
Version, cephalic, 338 
j combined, see Bimanual Version. 

! podalic, 339, 495 

Vertex, definition of term, 132 
Vestibule, 49 
Vitriform body, 106 

Voluntary muscles, action of, in labor, 248, 
i 256, 264 

i Vomiting, in pregnancy, 148, 213, 357 
I question of induction of labor in, 215, 

543 
I treatment of, 213, 214, 543 

Vulvo-vaginal follicles, sebaceous and mucip- 
I arous, 52 
I Vulvo-vaginal glands, 52 



"\I7EANING, dentition 
YV period of, 618 
Weed or ephemera, 594 



guide to proper 



rVONA pellucida, 



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current information which could not be accommodated in the Quarterly. It con- 
sisted of sixteen pasea of such matter, together with sixteen more known as tte 
Library Department and devoted to the publishing of books. With the increased 
progress of scierce, however, this was found insufiBcient, and some years since an- 
other periodical, known as the "Monthly Abstract," was started, and was fur- 
nished at a moderate price to subscribers to the "American Journal." These 
two monthlies will hereafter be consolidated, under the title of "The Medical 
News and Abstract," and will be furnished /ree of charge in connection with the 
" American Journal." 

The "News AND Abstract" will consist of 64 pages monthly, in a ceat cover. 
It will contain a Clinical Department in which will be continued the series of 
Original American Clinical Lectures, by gentlemen of the highest reputation 
throughout the United States, together with a choice selection of foreign Lectures 
and Hospifal Notes and Gleanings. Then will follow the Monthly Abstract, sys- 
tematically arranged and classified, and presenting five or six hundred articles yearly ; 
and each number will conclude with a News Department, giving current profes- 
sional intelligence, domestic and foreign, the whole fully indexed at the c^ose of 
each volume, rendering it of permanent valae for refeiecce. 

As stated above, the subscription price to the " News and Abstract" will be 
Two Dollars and a Half per annum, invariably in advance, at which rate it will rank 
as one of the cheapest medical peri, dicals in the country. But it will also be fur- 
nished, free of all charge, in commutation with the "American Journal op the 
Medical Sciences," to all who remit Five Dollars in advance, thus giving to the 
subscriber, for that very moderate sum, a complete record of medical progress 
throughout the world, in the compass of about two thousand large octavo pages. 

In this eflfort to furnish so large an amount of practical information at a price so 
unprecedentedly low, and thus place it within the reach of every member of the 
profession, the publisher confid nily anticipates the friendly aid of all who feel an 
interest in the dissemination of sound medical literature. He trusts, especially, that 
the subscribers to the "American Medical Journal" will call the attention of their 
acquaintances to the advantages thus oflered, and that he will be sustained in the 
endeavor to permanently establish medical periodical literature on a footing of 
cheapness never heretofore attempted. 

PREMIUM rOE OBTAINING NEW SUBSCEIBEES TO THE "JOUENAL." 
Any gentleman who will remit the amount for two subscriptions for 1880, one of 
which at least must be for a neiu subscriber, will receive as a premium, free by mail, a 
copy of any one of the following recent works : 

"Barnes's Manual of Midwifery" (fee p. 24), 

" TiiBURY Fox's Epitome of Disfases of the Sk n," new edition, just ready, 
(see p. 17). 

" Fothergill's Antagonism of Medicines" (see p. 16), 

"Holden's Landmarks, Medical and Surgical" (see p. 6), 

" Browne on the Use of the Ophthalmoscope" (seep. 20), 

"Flint's Essays on Conservative Medicine" (see p. 15), 

"Sturges's Clinical Medicine" (see p. 14), 

"Swayne's Obstetric Aphorisms," new edition (see p. 21), 

"Tanner's Clinical Manual" (see p. 5), 

"West on Nervous Disorders of Children" (see p. 20). 

\* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
complete sets for the year 1880. 

1^ The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
"Journal" may be made at the risk of the publisher, by forwarding in registered 
letters. Address, 

HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. 



Henry C. Lea's Publications — {Dictionaries). 



r\UNGLISON [EOBLEY), M.D., 

-^"^ Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Coe- 

taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulae for 
Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
someroyaloctavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
iJiist Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed forthe work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en • 
viable reputation. During the tfn years which have elapsed since the last revision, the additions 
to the nomenclature of the medical fcienceshave been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practi ioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary aremore numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typ >graphical arrangement has been much improved, rendering 
reference much more easy, and eviry care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorpm.ited with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 

may safely confirm the hope ventured by the editor 
•' that the work, which possesses for him a filial as well 



A book well known to our readers, and of which 
eyery Aaierican ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
ill the advancing science who«8 terms it defines. For- 
tunately, Dr. Richard J. Dunglison, having assisted his 
father ill the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
i nbued with the spirit of the book, has been able to 
eiit it. not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
lio-ent book readers, but to edit it as a work of the kind 
should be edited— to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr Dunglison has assumed and car- 
ried through, it is only necessary to stale that more 
than six thousand new subjects have been added in the 
present edition.— P/nZa. Med. Times, Jan 3, 1874. 

About the first book purchased by the medical stu 
deintisthe Medical Dictionary. The lexicon explana- 
to-y of technical terms is simply & sine qua no7i. In a 
s jience so extensive, and with such collaterals as medi 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious, ii 
was because Dunglison's met these indications that il 
became at once the dictionary of general use wherever 
medicine was studied in the English lan,a;uaee. In no 
former revision have the alterations and additions been 
so oreat. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 



letter, while the derivatives follow in small cap? 
a;Taa''emeut which greatly facilitates reference. 



We 



IS an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authoritv." — Cincinnati Clinic, Jan 10, 1874. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Mp.d.ion.l dntetff 

As a standard work of reference, as one of thebest, 
if not tbe very best, medical dictionary in the Eng- 
lish laoguHge. Dunglison's work has been well known 
for about forty years, and needs no words of praise 
on our part to recommend it to the members of the 
medical, and, likewise, of the pharmaceutical pro 
f,-s-ion. The latter especially are in need of such a 
work, which gives leady and reliable information 
on thousands of subjects and terms which they are 
liable to encounter in pursuing their daily avoca- 
tions, but with which they cannot be expected to be 
familiar. The work before us fully supplies this 
want. — Am. Journ. of Pharm., Feb. 1874. 

A valuable dictionary of tbe terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It re- 
flects great credit on its able American author, and 
well deserves the authority and popularity it has 
oh MVi^A.— British Med. Juurn., Oct. 31, 1874. 

Few works of this class exhibit a grander monu- 
ment of patient research and of scientific lore. The 
extent of the sale of this lexicon is sufficient to tes- 
tify to its usefulness, and to the great service con- 
ferred by Dr. Kjbley Dunglison on the profession, 
and indeed on others, hy its issne.— London Lancet, 
May 18 1*'75. 



no SLY N [RICHARD Z>.), M.D 

A DICTIONARY OF THE TERMS USED IN MEDICINE AT^D 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
l2mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00 
It-is the best book of defluitions we have, and ought always to be upon the student's tuble.— Southern 
Med. and Surg, fourna^ 



R 



OD WELL {G. F.), F.R.A.S., ^c 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
many illustrations : cloth, $5. 



Henry C. Lea's Publications — {Manuals), 



A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Doctors E. H. 
-^ Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- 
some 12mo. volume of about 350 pages : cloth, $2 25. {Just Ready.) 

This work appeared in the pages of the American Journal of the Medical Scieccef^ during the 
year 1876. A? a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



•nJEILL [JOHN), M.D., and ^MITH [FRANCIS G.), M.D., 

Prof, of the Institutes of Medicine inthe Univ. of Venn c. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12m < . 
volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 j strongly bound in 
leather, with raised bands, $4 75. 



J^ARTSHORNE [HENRY), M.D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one lar^e 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations r n 
wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 
We can say with the strictest truth that it is the | worthy. If students must have a conspectu.'?, they 
best work of the kind with which wf- artacquaiuted. j will be wise to procure that of Dr Harishurue — 
It embodies ina condensed form ail recent coutiibu- 1 Detroit Rev. of Med and Pharm., Aug 1874 

The work before us, however, has mauy redeem 

besides being admirably adapted to the use of stu 
dents of medicine. The book is faithfully and ably 
executed. — Charleston Med. Jonrn., April, 187.5 

The work is intended as an aid to the medical 
stulent, and as such appears to admirably fulfil its 
object by itsexcelleut arrangement, the full compi- 
lation jf facts, the pers^picuity aud terseness of lan- 
guage, and the clear and instructive illustrations 
in some parts of the work — American Journ. of 
Pharmacy, Philadelphia, July, 187-1. 

The volume will be found useful, not only to stu- 
dents, but to manyotherswhomay desire torefresh 
their memories with the smallest possible expendi- 
ture of time. — N. Y. Med. Journal, Sept. 187-1. 

The student will find this the most convenient and 
useful book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1874. 

This is the best book of its kind that we have ever 
examined. It is an honest, accurate, and conci.se 
compend of medical sciences, as fairly as possible 
representing their present condition. The chances 
and the additions have been so judicious and tho- 
rough as to render it, so far as it goes, entirely trust- 



;acqi 
il recent contiibu- 

tioas to practical medicine, ana is therefore useful | .^.^^^ ^ 

to every busy practition^er tbvoughout^ our country, j .^^ ^^.^^^,,^ ^^^t posses,-<ed by others. aLd is the be.-t 

we have seen. Dr. Hartshorne exhibits much skill in 
condensation It is well adapted to the physician lu 
active practice, who can give butlimiied time to the 
familiarizing of himself with the important changes 
which have been made since he attended lectures. 
The manual of physiology has also I een improved 
and gives the most comprehensive view of the late t 
advances in the science possible in the space devoted 
to the subject. The mechanical execution of the 
book leaves nothing to be wished for. — Peninsulnr 
Journal of Medicine, Sept 1874. 

After carefully locking through this conspectus, 
we are constrained to say that it is the most com- 
plete work, especially in its illustrations, of its kind 
that we have seen — Oincinna.ti Lancet, Sept. 1S74. 

The favor with which the first edition of this 
Compendium was received, was an evidence of i.s 
various excellences The present edition bears evi- 
dence of a careful and thorongh revision. Dr. Harts- 
horne possesi-es a happy faculty of seizing upon the 
sa'ient points of each subject, and of presenting them 
in a concise and yet perspicuous manner. — LeaV'.n^ 
worth Med. Herald, Oct. 1874. 



fUDLOW [J.L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



rPANNER [THOMAS HAWKES), M D., ^c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
&c. In one neat volume small 12mo., of about 375 pages, cloth, $150. 
*^* On page 4, it will be seen that this work is offered as a premium for procuring new 
subscribers to the "American Journal of the Medical Sciences." 



Henry C. Lea's Publications — (Anatomy). 



QRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George^ s Hospital, London. 

ANATOMY, DESCRIPTIYE AND SURGICAL. The Drawings by 

H. V. Carter, M.D., and Dr. Westmacott. The Dissectionsjointly by the Author and 
Dr. Carter. With an Introduction on General Anatomy and Development by T. 
Holmes, M.A., Surgeon to St. George's Hospital. A new American, from the eighth 
enlargec and improved London edition. To which is added " Laisdmarks, Medical and 
Surgical," by Luther Holden, F.R.C.S., author of " Human Osteology," " A Manual 
of Dissections," etc. In one magnificent imperial octavo volume of 98-3 pages, with 
♦ 522 large and elaborate engravings on wood. Cloth, $6 ; leather, raised bands, $7. 
[Just Ready.) 
The author has endeavored in this work to cover a more extendedrange of subjects than iscur- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, bvt 
also the application of those details in the practiceof medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid aeries, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Since the appearance of the last American Edition, the work has received three revisions at the 
hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
requisite to maintain its reputation as a complete and authoriti^-Mve standard text-book and work 
of reference. Still further to increase its usefulness, there bus been appended to it the recent 
work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" 
which gives in a clear, condensed, and systematic way, all the information by which the prac- 
titioner can determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. No pains have been spared in the typographical execution of 
the volume, which will be found in all respects superior to former issues. Notwithstanding the 
increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
at a price rendering it one of the cheapest works ever offered to the American profession. 



The recent work of Mr. Holden, which was no- 
ticed by us on p. 53 of this volume, has been added 
as an appendix, so that, altogether, this is the mott 
practical and complete anatomical treatise available 
to American students and phy.sicians. The former 
finds in it the necessary guide in making dissec- 
tions ; a very comprehensive chapter on minute 
anatomy; and about all that can be taught him on 
general and special anatomy; while the latter, in 
its treatment of each region from a surgical point of 
view, and in the valuable edition of Mr Holden, 
will 'find all that will be essential to him in his 
practice.— iV^ewj Remedies, Aug. 1878. 

This work is as near perfection as one could pos- 
sibly or reasonably expect any book intended as a 
text-book or a general reference book on anatomy 
to be. The American publisher deserves the thanks 
of the profession for appending the recent work of 
Mr. Holden, ''Landmarks, Medical and Sur gical,'" 
which has already been commended as a separate 
book. The latter work— treating of topographical 
anatomy— has become an essential to the library of 
every intelligent practitioner. We know of no 
book that can take its place, written as it is by a 
most distinguished anatomist. It would be simply 
a waste of words to say any thing further in praise 
of Gray's Anatomy, the text-book in almost every 
medical college in this country, and the daily refer- 
ence book of every practitioner who has occasion 



to consult his books on anatomy. The work is 
simply indispensable, especially this pre.'-^ent Amer- 
ican edition.— F«. Med. Monthly, Sept. 1S7P. 

The addition of the recent work of Mr. Holden, 
as an appendix, renders this the most practical and 
complete treatise available to American students, 
who find in it a comprehensive chapter on minuie 
anatomy, about all that can be taught on general 
and special anatomy, while its treatment of each 
region, from a surgical point of view, in the valu- 
able section by Mr. Holden, ia all that will be essen- 
tial to them in practice.— 0/uo Medical Recorder, 
Aug. 1S78. 

It is difiicult to speak in moderate terms of this 
new edition of "Gray." It seems to be as nearly 
perfect as it is possible to make a book devoted to 
any branch of medical science. The labors of the 
eminent men who have successively revised the 
eight editions through which it has passed, would 
seem to leave nothing for future editors to do. The 
addition of Holden's " Landmarks" will make it as 
indispensable to the practitioner of medicine and 
surgery as it has been heretofore to the student. As 
regards completeness, ease of reference, utility, 
beauty, and cheapness, it has no rival. No stu- 
dent should enter a medical school without it ; no 
physician can afford to have it absent from his 
library. — Sc. Louis Clin. Record, Sept. 1878. 



R 



Also for sale separate — 
'OLDEN [LUTHER), F.R.C.S., 

Surgeon to St. Bartholomew' s and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 

Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. {Now Ready.) 



TJEATH [CHRISTOPHER), F.R.C.S., 

a1 Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247illustrationg. Cloth, $.3 50 ; 
leather, $4 00. 



Henry C. Lea's Publications — {Anatomy). 



A LLEN [HARRISON), M.D. 

-^^ Profesf-or of Phy-nology in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an 
Introductory Chapter on Histology. ByE. 0. Shakespeare, M D., Ophthalmologist to the 
Phila. Hosp. In one large and handsome quarto volume, with several hundred original 
illustrations on lithographic plates, and numerous "wood-cuts in the text. (Preparing.) 
In this elaborate work, which has been in active preparation for several years, the author has 
sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
the practical applications of the science to medicine and surgery. The work thus has claims upon 
the attention of the general practitioner, as well as of the student, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize the significance of allvaria- 
tions from normal conditions. The marked utility of the object thus sought by the author is 
self-evident, and his long experience and assiduous devotion to its thorough development are a 
suflBcient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original dissections, drawn on 
stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
after the manner of " Holden" and " Gray, " and in every typographical detail it will be the 
effort of the publisher to render the volume worthy of the very distinguished position which is 
anticipated for it. 

rpiLIS [GEORGE VINER), 

J~^ Eraeritus Professor of Anatomy in University College, London, 

DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised London 
Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
Cloth, 84.25 ; leather, $5.25. {Jvst Ready.) 
This work has long been known in England as the leading authority on practical anatomy, 
and the favorite guide in the dissecting-room, as is attested by the numerous editions through 
which it has passed. In the last revision, which has just appeared in London, the accomplished 
author has sought to bring it on a level with the most recent advances of science by making the 
necessary changes in his account of the microscopic structure of the different organs, as devel- 
oped by the latest researches in textural anatomy. 

Ellis's DemoQstrations is the favorite text-book its leadership over the English manuals upon dis- 
of the English student of anatomy. In passing secting.— P/ii7rt. Med. Times, May 24, 1S79, 
through eight editions it has been so revised aod 

adapted to the needs of the student hat it tvould ^^ ^ dii^sector, or a work to have in hand and 
seem that it had almost reached perfection in ibis studied while one is engaged in dissecting, we re- 
special line. The descriptions are clear, and the S^^'d i' ^^ the very best work extant, which is cer- 
methods of pursuing anatomical investigations are tainly saying a very great deal. As a text-book to 
given with such detail that the book is honestly be studied in the dissecting-room, it is superior to 
entitled to its name.— S'i. Louis Clinical Record, ^-^^ "f ^he works upon ^n^tomj .— Cincinnati Med. 
June, 1S79. i ^^f^s, May 2-t, 1S79. 

The success of this old manual seems to be as well "We most unreservedly recommend it to every 

deserved in the present as in the past volumes. I practitioner of medicine who can possibly get it. 

The book seems destined to maintain yet for years i Va. Med. Monthly, June, 1879. 



TJTILSON [ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and SpeciaL Edited 

by W. H. GoBRECuT, M.D , Professor of General and Surgical Anatomy in the Medical Col 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather, $5. 

^MITH [HENRY H.), M.D., and JJORNER [ WILLIAM E.),M.D., 

Prof, of Surgery in the Univ. of Penna. , &c. Late Prof, of Anatomy in the Univ. ofPenna. 

AN ANATOMICAL ATLAS ; illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiiul figures. $4 50. 



s 



CHAFER [ED WARD ALBERT), M.D., 

As.sistant Professor of Physiology in University College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with 
numerous illustrations: cloth, $2 00. {Just Issued.) 



HORNER'S SPECIAL ANATOMY AND HISTOL- BELLAMY'S STUDENT'S GUIDE TO SURGICAL 
OGY. Eighth edition, extensively revised and j ANATOMY: A Text-book for Students preparirs 



^d. In 2 vols. 8vo., of over 1000 pag€ 
with 320 wood-cnts : cloth, $6 00. 
SHARPEY AND QUAIN'S HUMAN ANATOMY. 
Revised, by Joseph Leidt, M.D., Prof of Anat. 
in Uuiv. of Penn. In two octavo vols, of about 
1300 pages, with 511 illustrations. Cloth, $6 00. 



for their Pass Examiration. With engravings oi 
wood. In one handsome royal 12mo. volume 
Cloth, $2 2.5. 
CLELAND'S DIRECTORY FOR THE DISSECTION 
OF THE HUMAN BODY. In one small volume 
royal 12mo. of 182 pages: cloth fl 25. 



Henry C. Lea's Publications — {Physiology). 



/JARPENTER [WILLIAM B.), M.D., F.R. S., F.G.S., F.L.S., 

Registrar to University of London, etc. 

PRIKCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, 

M.B. Lond., F.R.C.S., Examiner in ISatural Sciences, University of Oxford. Anew 
American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
tions, hy Francis G. Smith, M.D., Professor of the Institutes cf Medicinein the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octa-v o v^olume, ol 1083 pages, 
with two plates and 378 engravings on wood ; cloth, $5 50 ; leather, $6 50. [Just Issued.) 

Thegreat work, the crowning labor of the distinguished author and through which so many 
generations of students have acquired their knowledge of Physiology, has been almost meta 
morphosed in the effort to ar fipt it thoroughly to the requirements of modern science. Since 
the appearance of the last American edition, it has had several revisions at the experienced 
hand of Mr. Power, who has modified and enlarged it so as to introduce all that is important 
in the investigation^ and discoveries of Enghmd, France, and Germany, resulting in an enlarge- 
ment of about one-fourth in the text. The series of illustrations has undergone a like revision , 
a large proportion of the former ones having been rejected, and the total number increased 
to nearly four hundred. The thorough revision which the work has so recently received in 
England, has rendered unnecessary any elaborate additions in this country but the American 
Editor, Professor Smith, has introduced such matters as his long experience has shown him to 
be requisite for the student. Every care has been taken with the typographical execution, and 
the work is presented, with its thousand closely, but clearly printed pages, as emphatically the 
text-book for the student and practitioner of medicine — the onein which, asheretofore, especial 
care is directed to show the applications of physiology in the various practical branches of 
medical science. Notwithstanding its very great enlargement, the price has not been in- 
creased, rendering thif one of the cheapest works now before the profession. 

subject, perfectly certain of the fulness of information 
it will cunvey, and well satisfied of the accuracy witli 
which it will there be found stated. — London Med. 
Times and Gazette, Feb. 17, 1877. 

Thus fully are treated the structure and functions of 
all the important organs of the body, while there are 
chapters on sleep and somnambulism; chapterson eth- 
nology, a full section on generaiion, and abundant re- 
ferences to the curiosities of physiology, as the evolu- 
tion of light, heat, electricity, etc. In short, this new 
edition of Carpenter is, as we have said at the start, 
a very encyclopedia of modern physiology. — The Clin- 
ic. Veh 24. 1877. 

The merits of "Carpenter's Physiology" are so widely 
known and appreciated ihat we need only allude briefly 
to tlie fact that in the latest edition will be found a coai- 
prehensive embodiment of the results of recent physio 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bear," 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr. Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition. — N. Y. Med. Journal, J a.n. 1817 . 

A more thorough work on physiology could not be 
found. In this all the facts discovered by the late re- 
searches are noticed, and neither student nor practi- 
tioner should be without this exhaustive treatise on an 
important elementary branch of medicine. — Atlanta 
Med. and Surg. Journal, Dec. 1876. 



We have been agreeably surprised to find the vol 
ume so complete in regard to the structure and func- 
tions of the nervous system in all its relations, a 
subject that, in manyrespects, is one of the mostdifH- 
cult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatii^e of 
the class to which the one before us belongs. The 
additions by the American editor give to the work as 
it is a considerable value beyond that of the last 
English edition. In conclusion, we can give our cor- 
dial recommendation to the work as it now appears. 
The editors have, wiih their additions to the only 
work on physiology in our language that, in the full- 
est sen-e of the word, is the production of a philoso- 
pher as well as a physiologi.'-t, brought it up as fully 
as could be expected, if not desired, to the standard 
i>f our knowledge of its subject at the pretent day. 
It will deservedly maintain the place it has always 
had iu the favor of ihe medical profession. — Journ. 
of Nervous and Mental Duease, April, 1877. 

"Good wine needs no bush" says the proverb, and 
an old and faithful servant like the '"big" Carpenter, as 
carefully brought down as this edition has been by Mr. 
Henry Power. Leeds little or no commendation by us. 
Such enormous advances have recently been made in 
our physiological knowledge, that what was perfectly 
new a year or two ago. looks now as if it had been a 
ri-ceived and established fact for years. In this ency- 
copwdic way it is unrivalled. Here, as it seems to 
us. is thegreat value of the book: one is safe in sending 
a student to it for information on almost any given 



JZIRKES ( WILLIAM SENHO USE), M.D. 

A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 

IM.D., F.R.C.S. A new American from the eighth and improved London edition. "Vk ith 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 75. {Lately Issued.) 

On the whole, there is very little in the book , physiology which we havein our language.— iV. Y. 
whicheitherthesludent or practitionerwillnot find I M'fici TJecorc?, April 15, 1873. 
of pi aciical vulue and consistent with our present I 

knowledge of this rapidly changing s-cience; and we | ^° ^^^ enlarged form it is, in ouropinion, still the 
have no hesitation in expres sing our opinion that I bestbookon physiology, most useful to thestudent 



this eighth edition is one of the best handbooks 



-Phila. Med. Times, Aug. 30, 1873. 



HARTSHOKNE'S HANDBOOK OF ANATOMY AND 
PHYSIOLOGY. Second edition, revised. In one 
royal 12mo. vol., with 220 wood cuts ; cloth, 
*1 75. 

LEHMANN'S MANUAL OF CHEMICAL PHYSIOL- 
OGY. Translated frcm the Geiaan. with Notes 



and Additions, by J Cheston Morbts, M.D. With 
illustrations on wood. In one octavo volume of 
336 pages. Clo'h, $2 2.5. 
LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- 
plete in two laige octavo volumes of 1200 p^ges, 
with 2C0 illustrations; cloth, $6. 



IIenry C. Lea's Publications — (Physiology^ CJiemistrij). 9 

fiALTON {J, a), M.D., 

■*-^ Prnfessor of Physiology in the Oollege of Physicians and Surgeons, New York, &c. 

A TREATISE ON EIUMAX PHYSIOLO&Y. Designed for the use 

of Studentpand Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hun ired and sixteen illustrations on wood. In one very beautiful octavo vol- 



ume, of over 800 pages. Cloth, $5 50 ; 1 
During the past few years several new works on phy- 
siology, and new editions of old work.«. have appeared, 
competing for the favor of the medical student, but 
none -vill rival this new edition of D;i]ton. As now en- 
larged, it will be found also to be. in general, a satisfac- 
tory work of reference for the practitioner. — Chicago 
Med. Jnurn. jud Examiner. ^a.n. 1876. 

Prof. Dalton has discussed conflicting theories and 
conclusions regarding physiological questions with a 
fairness, a fulness, and a conciseness which lend fresh- 
ness and vittor to the entire hook. But his discussions 
have been so guarded by a refusal of admission to those 
speculative and theoretical explanations, which at best 
exist in the minds of observers themselvesas only pro- 
babilities, that none of his readers need be led into 
ffrave errors while makicg them a study. — The Medical 
Record, Feb. 19, 1876. 
The revision of this great work has broughtitforward 



athe 
Thi 



$6 50. iJicst Issued.) 

popular tex;'-book on uhysiology comes to us in 



it='. sixth eiition with theaddition of about fifty percent, 
of new matter, chiefly in the departments of patho- 
logical chemistry and the nervous systtm. where the 
principal advances have been realized. With so tho- 
rough revision and addifious, that keepthe work well 
up to the times, its continued p'^pularity may bi' confi- 
dently oredicted, notwithstanding the comoctition it 
may encounter. The publisher's work is admirably 
done. — St. Lnuis Med. and Surg. Journ , Dec. 1875 

We heartily welcome this, the sixth edition of thif? 
admirable rext book, than which thereare none of equal 
brevity more valuable. It iscordially recommended by 
the Professorof Physiology in the University of Louisi- 
ana, as by all competent teachers in the United States, 
and wherever the English language is read, this bock 
has been appreciaed. The present edition, with its:116 
admirably executed illustrations. has been carefully 



ith the physiological advances of the day. and renders I revi.^ed and very much enlarged.althoush its bulkdoes 



it, as it has ever been, the finest work for studi 
UnL—JVashville Journ. of Med. and Surg.. Jan. 1876. 

For clearness and perspicuity. Daltoii's Physiology 
commended itself to the student years ago. and was a 
pleasant relief from the verbose productions which it 
supplanted. Physiology h;is. however, made many ad- 
vances since then — and while the style has been pre- 
served intact, the work in the present edition has been 
broufflitupfully abreast of thetimes. Thenew chemical 
notation and nomenclature have also been introduced 
into the present edition. Notwithsiandinq: the multi- 
plicity of text-books on physioIoLry. this will lose none 
of its old time popularity. The mechanical execution 
of the work is all that could be desired. — Peninsular 
Journal of Medicine, Dec. 1875. 



not seem perceptibly increased. — New Orleans Medical 
and Surgical Jownal. ilarch. 1876. 

The present edition is very much superior to every 
other, not only in that it brings the subject up to the 
times, but that 1+ do'>s so more fully and satisfactorily 
than any previous edition. Takeit altogether it remains 
inourhumbleopinion.thebest text book on physiology 
in any land orlanaiuage. — The Clinic, yov. 6, 1875. " 

As a whole, we cordially recommend the work 3S a 
text-book for the student, and as one of the best. — 
The Journal of Xervnus and Mental Disease, Jan. 1876. 

Still holds its position as a masterpiece of lucid writ- 
in?. and is, we believe, on the whole, the best book to 
place in the hands of the student. — London Students^ 
Journal. 



(ILASSEN {ALEXANDER), 

^^ Prnfe.9.<?or in the Royal Polytechnic School, Aix la-Chapelle. 

ELEMENTARY QUAXTITATIYE ANALYSIS. Translated with 

notes and additions by Edgar F. S.uith, Ph.D., Assistant Prof, of Chemistry in the 

Towne Scientific School, Univ. of Penna. In one handsome royal 12mo. volume, of 324 

pages, with illustrations; cloth, $2 00. {Just Ready.) 

It is p.obably the bast minaal of aa elementary | advancing to the analysis of minerals and such pro- 

nature extant, insomuch as its methods are the best. | ducts as are met with in applied chemistry. It is 

It teaches by examples, commencing with single ; an indispensable book for students in chemistry. — 

determinations, followed by separations, and then I Boston Journ. of Chemistry, Oct. 1878. 



flALLOWAY [ROBERT), F.C.S., 

^^ Prof of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIYE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. {Lately 
Issned. ) 

JDOWMAN [JOHN E.),M.D. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- 
ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. 
^Y THE SAME AUTHOR. 



PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. 

edition. In one neat volume, royal 12mo. {Prepari)?g.) 



N 



ew 



E 



EMSEN[IRA), M.D., Ph.D., 

Professor of QheraiRtry in the Johns Hopkins University, Baltimore. 

PRINCIPLES OF THEORETICAL CHEMISTRY, with speoial reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. {Just Issued.) 

TXrOHLER AND FITTIG. 

^^ OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 

ditions from the Eighth German Ed. By Ira Remsen, M.D., Ph.D., Prof, of Chem- 
andPhysics in Williams College, Mass. In one volume, royal 12mo.of 550 pp., cloth, |3, 



10 



Henry C. Lea's FvbJjIGations— (Chemistry). 



POWNES {GEORGE), Ph.D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. Revised and corrected by Henry Watts, B.A., F R.S., author of "A Diction- 
ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
trations. A new American, from tht twelfth and enlarged London edition. Edited by 
Egbert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; 
cloth, $2 75 ; leather, $3 25. {Jicst Ready.) 
Two careful revisions by Mr. Watts, since the appearance of the last American edition of 
" Fownes," have so enlarged the work that in England it has been divided into two volumes. In 
reprinting it, by the use of a small and exceedingly clear type, cast for the purpose, it has been 
found possible to comprise the whole, without omission, in one volume, not unhandy for study and 
reference. The enlargement of the work has induced the American Editor to confine his additions 
to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- 
nounced since the very recent appearance of the work in England, and has added the standards 
in popular use to the Decimal and Centigrade systems employed in the original. 

Among the additions to this edition will be found a very handsome colored plate, representing 
a number of spectra in the epectroscope. Every care has been taken in the typographical execu- 
tion to render the volume worthy in every respect of its high reputation and extended use, and 
though it has been enlarged by more than one hundred and fifty pages, its very moderate price 
will still maintain it as one of the cheapest volumes accessible to the chemical student. 



This work, inorganic and organic, is complete in 
one convenient volume. In its earliest editions it 
was fully up to the latest advancements and theo- 
ries of that time. In its present form, it presents, 
in a remarkably convenient and satisfactory man- 
ner, the principles and leading facts of the chemistry 
of to-day. Concerning the manner in which the 
various subjects are treated, much deserves to be 
said, and mostly, too, in praise of the book. A re- 
view of such a work af Fownes's Ghennistry within 
the limits of a book-notice for a medical weekly is 
simply out of the question. — Cincinnati Lancet and 
Clinic, D.-C. 1-1, 1S7S. 

When we state that, in our opinion, the present 
edition sustains in every respect the high reputation 
which its predecessors have acquired and eujoyed, 
we express therewith our fall belief in its intrinsic 
value as a text-book and work of reference. — Am. 
Journ. of Pharm., Aug. 1878. 

The conscientious care which has been bestowed 
upon it by the American and English editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



what formidable magnitude with its more than a 
thousand pages, but with less than this no fair repre- 
sentation of chemistry as it now is can be given. The 
type is small but very clear, and the sections are very 
lucidly arranged to facilitate study and reference. — 
Med- and Surg. Reporter, Aug 3, 1878. 

The work is too well known to American students 
to need any extended notice ; suffice it to say that 
the revision by the English editor has been faithfully 
done, and that Professor Bridges has added some 
fresh and valuable matter, especially in the inor- 
ganic chemistry. The book has always been a fa- 
vorite in this country, and in its new shape bids 
fair to retain all its former prestige. — Boston Jour, 
of Chemistry , Aug. 1878. 

It will be entirely unnecessary for us to make any 
remarks relating to the general character of Fownes' 
Manual. For over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from time 
to timeleavelittlechance for any wideawaberival to 
step before it.— Canadian Pharm. Jour., Aug. 1878. 

As a manual of chemistry it is without a superior 
in the language.— Ifd, Med. Jour., Aug. 1S7S. 



A TTFIELD {JOHN), Ph.D., 

•^^ Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; 

including the Chemistry of the U. S. Pharmacol oeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Eighth edition revised 
by the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. 

Cloth, $2 50 ; leather, $3 00. {Just Ready.) 



We have repeatedly expressed our favorable 
opinion of this work, and on the appearance of a 
new edition of it, little remains for us to say, ex- 
cept that we expect this eighth edition to be as 
indispensable to us as the seventh and previous 
editions have been. While the general plan and 
arrangement have been adhered to, new matter 
has been added covering the observations made 
since the former edition The present differs from 
the preceding one chiefly in these alterations and 
in about ten pages of useful tables added in the 
appendix.— ^m. Jour, of Pharmacy, May, 1879. 

A standard work like Attfield's Chemistry need 
only be mentioned by its name, without further 
comments The present edition contains such al 
terations and additions as seemed necessary for 
the demonstration of the latest developments of 
ch€mical principles, and the latent applications of 
chemistry to pharmacy. The author has bestowed 
arduous labor on the revision, and the extent of 
the information thus introduced may be estimated 
from the fact that the index contains three hun- 
dred new references relating to additional mate- 
rial. — Druggists^ Circular and Chemical Gazette. 
May, 1879. 

This very popular and meritorious work has 
now reached its eighth edition, which fact speaks 
in the highest terms in commendation of its excel 
lence. It has now become the principal text-book 



of chemistry in all the medical colleges in the 
United States. The present edition contains such 
alterations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest applications of 
chemistry to pharmacy. It is scarcely necessary 
for us to say that it exhibits chemistry in its pre- 
sent advanced state. — Cincinnati Medical Ntws, 
April, 1879. 

The popularity which this work has enjoyed is 
owing to the original and clear disposition of the 
facts of the science, the accuracy of the details, and 
the omission of much which freights many treatises 
heavily without bringing corresponding instruction 
to the reader. Dr. Attfield writes for students, and 
primarily for medical students ; he always has an 
eye to the pharmacopoeia and its officinal prepara- 
tions; and he is continually putting the matter in 
the text so that it responds to the questions with 
which each section is provided. Thus the student 
learns easily, and can always refresh and test his 
knowledge.— ilferf ar.d Surg. Reporter, Aprill9,'79. 

We noticed only about two years and a half ago 
the publication of the preceding edition, and re- 
marked upon the exceptionally valuable character 
of the work. The work now iacludes the whole of 
the chemistry of the pharmacopoeia of the United 
States, Great Britain, and l^&va,.—New Remedies, 
May, 1879. 



Henry C. Lea's Publications — {Chemistry). 



11 



T>LOXAM [G.L.], 

-*-' Profeftsor of Chemintry in King'' s College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lor 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus 
trations. Clotli, $4 00 j leather, $5 00 
have in this work a complete and most excel- 



W 

lent text-book for the use of schools, and can heart- 
ily recommend it at^such. — Boston Med. and Surg. 
Journ., May 2S, 1874. 

The above is the title of a work which we can most 
conscientiously recommend to students of chemis- 
try. It is as easy as a work on chemistry could be 
made, at thesame time that it preseutsa fullaccount 
of thatscience as it now stands. We have spoken 
of the work as admirably adapted to the wants of 
students ; it is quite as well suited to the require- 
ments of practitioners who wish to review their 
chemistry, or have occasion to refresh their memo- 
ries on any point relating to it. In a word, it is a 
book to be read by all who wish to know what is 
the chemistry of the present day. — American Prac 
titioner, Nov. 1873. 



{Lately Issued.) 

It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
c^ clop^edia within the limits of aconvenient volume, 
and has done so without penning ;he usel€,s-s para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive 
scientist is not disappointed when he looks for the 
record of new and valuable proces.>es and discover- 
ies, while the cautious conservati^ e does not find its 
pages monopolized by uncertain theories and specu- 
lations. A peculiar point of excellence is the crys- 
tallized form of expression in which great truths are 
expressed in very short paragraphs. One is surprised 
at the brief space allotted to an important topic, and 
yet, after reading it, he feels that little, if any more 
should have been said. Altogether, it is seldom yoa 
see a text-book so nearly faultless. — Cincinnati 
Lancet Nov. 1873. 



C^ 



LOWES (FRANK), D.Sc, London. 

Senior Science- Master at the High School, Newcastle-uvder Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTIC 4L CHEMISTRY 

AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 
English Edition, with about fifty illustrations on wood. In one very handsome royal 
12mo. volume of 372 pages : cloth, $2 50. {Now Ready.) 

are so simple, and yet concise, as to be interesting 
and intellig'ble. The work is unincumbered with 
theoretical deductions, dealing wholly with the 
practical matter, which it is the aim of this compre- 
hensive text-book to impart. The accuracy of the 
analytical methods are vouched for from the fact 
that they have all been worked through by the 
author and the members of his class, from the 
printed text. We can heartily recommend the work 
to the .xtudent of chemistry as being a reliable and 
comprehensive one. — Druggists' Advertiser, Oct. 
15, 1877. 



It is short, concise, and eminently practical. We 
therefore heartily commend it to students, and e«pe- , 
cially to those who are obliged to dispense with a 
master. Of course, a teacher is in every way desi- 
rable, but a good degree of technical skill and prac- 
tical knowledge can be attained with no other 
instructor than the very valuable handbook now 
under consideration. — St. Louis Clin. Record, Oct. 
1877. 

The work is so written and arranged that it can be 
comprehended by the student without a teacher, and 
the descriptions and directions forthe various work 



KN i.PP'S TECHNOLOGY ; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
additions by Prof. Walter R. Johnson. In two 



very handsome octavo volumes, with 500 wood 
engravings, cloth, $6 00. 



ARRISH {EDWARD), 

Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 

L TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth, $5 50 ; leather, $6 50. 
(Lately Issued.) 

the work, not only to pharmacists, but also to the 
multitude of medical practitioners who are obliged 
to compound their own medicines. It will ever hold 



Of T)r Parri.-ih's great work on pharmacy it only 
remains to be said that the editor has accomplished 
his work so well as to maintain, in this fourth edi- 
tion, the high standard of excellence which it bad an honored place on our own book^sholves. — Dublin 
attained in previous editions, under the editorship ofj Med. Press and Circular, Aug. 12, 1874. 
its accomplished author. This has not been accom 



We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen in to 
competent hands. It is a book with which no pharma- 
cist can dispense, and from which no physician can 
fail to derive much information of value to him in 



plished without much labor, and many additions and 
improvements, involving changes in the arrange- 
ment of the several parts of the work, and the addi- ' 
tion of much new matter. With the modifications 
thus effected it constitutes, as now presented, acom- ! 
pendium of the science and art indispensable to the j 

pharmacist, and of the utmost value to every i ,, .^ ,, ^ ^„ 

practitioner of medicine desirous of familiarizing; practice.— Pa (n;?c Med. and S^lrg. Journ., Suxie,'li. 
himself with the pharmaceutical preparation of the 'i Perhaps one, if not the most important book upon 
articles which he prescribes for his patients.— C/ii- 1 pl^armacy which has appeared in the English Ian- 
cago Med. J"o«rn., July, 1874. j g„age has emanated from the transatlantic press. 

The work is eminently practical, and has the rare' "Parrish's Pharmacy" is a well-known work on this 
merit of being readable a-nd interesting, while it pre- side of the water, and the fact shows us that a really 
serves astrictly scientificcharacter. The whole work useful work never becomes merely local in its fame, 
reflects the greatest credit on author, editor and pub- Thanks to the judicious editing of Mr. Wiegand, the 
lisher. It will convey someidea of the liberality which posthumous edition of "Parrish" has been saved to 
hasbeen be-^towed upon itsproduction when we men- : the public with all the mature experience of its au- 
tion thatthereare no less than 2S0carefully executed thor, and perhaps none the worse for a dash of new 
illustrations. In conclusion, we heardly recommend blood. — Lond. Phar^m,. Journal, Oct. 17, 1874. 



12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 



F 



JARQUHARSON {ROBERT), M.D., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- 

ond American edition, revised by the Author. Enlarged and adapted to the U. S. 
Pharmacopoeia. By Frank Woodbury, M.D. In one neat roj al 12mo. volume of 498 
pages: cloth, $2.25. {Just Ready.) 

This work contaius in moderate compass such 
well-digested facts concerniug the physiological 
and therapeutical action of rercedies as are reason- 
ably established up to the present time. By a con- 
venient arrangement the correspondirg effects of 
each article in health and disease are presented in 
parallel Cilumns, not only rendering reference 
easier, but also impressing the facts more strongly 
upon the mind of the reader. The book has been 
adapted to the wants of the American student, and 
copious notes have been introduced, embodying the 
latest revision of t>e Pharmacopoeia, together wi h 
the antid tes to the more prominent poisons, and 
such of the newer remedial agenti^ as seemed neces- 
sary r.o the completeness of the work. Tables of 
weights and mea.sures, and a good alphabetical in- 
dex end the volume. — Druggists' Circular and 
Ohendeal Gazette, June, 1879. 

It is a pleasure to think that the rapidity with 
which a second edition is demanded may be taken 
as an indication that the sense of appreciation of the 
value of reliable information regarding the use of 
remedies i- not entirely overwhelmed in the cultiva- 
tion of pathological studies, characteristic of the pre- 
sent day. This work certainly merits the success it 
has go quickly acbieved. — New Remedies, July, '79. 



The appearance of a new edition of this cf>nve 
nient and handy book in less than two years may 
certainly be taken as an indication of its useful 
ness. Its convenient arrangement, and its terse- 
ness, and, at the same time, comoie^eness of the 
information given, make it a handy book of refer- 
ence. — Am. Journ. of Pharmacy, June, 1879. 

The early appearance of a second eiition of Dr. 
Farquharson's work bears sufficient testimony to 
the appreciation of it by American readers. The 
plan is such as to bring the character and action of 
drugs to the eye and mind with clearness Tne 
care with which both author and ed tor have done 
their work is conspicuous on every page. — Med. and 
Surg. Reporter, May 31, 1879. 

The second edition, enlarged and revised, is a 
happy medium between the first edition, which 
was rather too brief on some important matters, 
and the large octavos of Wood and Birtholow. It 
is brought up to the most recent researches, one 
no'e referring to an article published in Aoril of 
this year. The favorable reception accorded it, 
shown by this reissue in two years, was one well 
mevited.— Louisville Med. News, June 7, 1879. 



^TILLE [ALFRED), M.D., 

Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth edition, revised and enlarged. In two large and handsome 8vo . vols, of about 2000 
pages. Cloth, $10; leather, $12. {Lately Issued.) 



It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known and excellent wor^.— Brit, and For. 
Med.-Ghir. Review, Oct lb75. 

For all whodesire a complete work on therapeutics 
and materia medica for reference, in casesinvolving 
medico-legal questions, as well as for information 
concerning remedial agents, Dr. Still^'s is '■'"par ex- 
cellenoe" the work. The work beingout of print, by 
theexhaustion of former editions, the author has laid 
the profession under renewed obligations, by the 
careful revision, importantadditious, and timely re 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Louis Med. and Surg. Journal, Dec 1874. 

From the publication of the first edition "Stilld's 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 
guage, and its presence supplies, in the two volumes 



of the present edition, a whole cyclopsedia of thera- 
peutics. — Chicago Medical Journal, Feb. 1875. 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profes!-ion, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict, as the work has been care- 
fully revi.sed and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and croton chloral, nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminnm, and other remedies.— .im. 
Journ. of Pharmacy, Feb. 1875. 

We can hardly admit that it has a rival in the 
rauUitflde of its citations and the fulness of its re- 
search into clinical histories, and we must as.sign it 
a y)lace in the physician's library; not, indeed, as 
fully representing the present state of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question. — Boston Med. and. Surg. Journal, Nov..', 
1874. 



ffRIFFITH {ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physiciar s and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, b^ John M. 
Maisch, Professorof Materia Medica in the Philadelphia College of Pharmacy. Inonelarge 
andhandsome octavo volumeof aboutSOOpp., cl., $450; leather, $5 50. {Lately Issued) 
To the druggist a good formulary is simply indis- A more complete formulary than it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitioner 
who compounds his own medicines. Much of what 
is contained in the introduction ought to he com- 
mitted to memory by every student of medicine. 
As a help to physicians it will be found invHlnable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
— The American Practitioner, Louisville, July, '74. 



peusable, and perhaps no formulary has been more 
extensively used than the well-known work before 
us. Many physicians have toofficiate, also, as drug- 
g'sts. This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 
t^iH kind is of benefit also to the city physicinn in 
largest practice.— Ginci7inati Dlinic, Feb. 21, 1874. 



Henry C. Lea's Publications — {3Iat. Med. and Therapeutics). 13 



QTILLE [ALFRED], M.D., LL.D., and JlfAISCH {JOHN M.), Ph.D.. 

O Pro/ of Theory and Practice of Medicine ■^'-'- Prof, of Mat. Med. and Bot. in Phil 



and of Clinical Med. in Univ. of Pa. 



Coll. Pharmacy, Secy, to the Araerican 
Pharmaceutical A-isociaJi on. 



THE NATIONAL DISPENSATOKY : Containing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
the Pharmacopoeias of the United States, Great Britain, and Germany, with numer- 
ous references to the French Codex. Second edition, thoroughly revised, with numerous 
additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. 
Extra cloth, $6 75; leather, raised bands, $7 50. {Now Ready ) 
Preface to the Second Edition. 

The demand which has exhausted in a few months an unusually large edition of the National 
Dispensatory is doubly gratifying to the authors, as showing that they were correct in thinking 
that the want of such a work was felt by the medical and pharmaceutical professions, and that 
their efforts to supply that want have been acceptable. This appreciation of their labors has 
stimulated them in the revision to render the volume more worthy of the very marked favor 
with which it has been received. The first edition of a work of ."^uch magnitude must necessarily 
be mnre or less imperfect ; and though but litt'e that is new and important has been brought 
to light in the short interval since its publication, yet the length of time during which it was 
passing through the press rendered the earlier portions more in arrears than the la'er. The 
opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to 
introduce alterations and additions whereve* there has seemed to be occasion for imnrove- 
ment or greater completeness. The principal changes to be noted are the introduction of seve- 
ral drufirs under separate headings, and of a large number of drugs, chemicals, }«nd phaima- 
ceutical preparations classified as allied dmgs and preparations under the heading of more 
important c better known articles : these additions comprise in part nearly the entire German 
Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
came to the authors' notice up to the time of publication have received due consideration. 

The series of illustrations has undergone a corresponding thorough revision. A number have 
been added, and still more have been substituted for such as were deemed less satisfactory. 

Thf new matter embraced in the text is equal to nearly one h'lndred pages of the first edition. 
Considerable as are these changes as a whole, they have been accommodated by an enlargement 
of the page without increasing unduly the size of the volume. 

While numerous additions have been ma'^e to the sections which relate to the physiological 
action of medicines and their use in the treatment of disease, great care has been taken to 
make them as concise as was possible without rendering them incomplete or obscure. The 
doses have been expressed in the terms both of troy weight and of the metrical system, for the 
purpose of mak'ng those who employ the Dispensatory familiar With the latter, and paving the 
way for its introduction into general use. 

The Therapeutical Index has been extended by about 2250 new references, making the total 
number in the present edition ab< ut 6000. 

The articles there enumerated as remedies for particular diseases are not only those which, 
in the authors' opinion, are curative, or even beneficial, but those also which have at any time 
been employed on the ground of popular belief or professional authority. It is often of as 
much consequence to be acquainted with the worthlessness of certain medicines or with the 
narrow limits of their power, as to know the well attested virtues of others and the conditions 
under which they are displayed. An additional value possefsed by such an Index is, that it 
contains the elements of a natural classification of medicines, founded upon an analysis of the 
results of experience, which is the only safe guide in the treatment of disease. 

A few notices of the previous edition are appended. 

To the pvofessioa at large, then, we will appeal 
when we say that the Messrs. Churchills have done 
a public service in introducing this book to Engli.-^h 
readers. As far as we can see on that peru.sal 
which can alone be given to books which are only 
intended to be books of reference, we should say 
that this is probably tbe most perfect book of its 
kind now available. It is emphatically, we would 
repeat, a book for the practi ioner, one well calcu- 
lated to give hioa hints as to treatment, and most 
suggestive a-; to remedies. It would be difldsnlt for 
us to sav more. — London Med. Times and Gazette, 
July 12; 1870 

We intend to draw the attention of our brother 
pharmacists to this publication, which cannot fail 
to exercise a widespread and in trkedinfluence upon 
the discharge of the duties of their vocation. The 
material embodied in the work is truly immense, 
as shown alone by the almost countless number < f 
subjects treated. We congratulate theauthorsupon 
their success in having brought to a close a work 
which must inevitably take its place as one of the 
most important con ributions to medical and phar- 
maceutical literature. — ^m. Journ. of Pharm , 
May, 1S79. 

The aspociation of such distinguished authors as 
Professors Stilleand Maisch in the composition r.f a 
work of this character has excited the strongest in- 
terest and the highest expectations in the mind of 
every physician and pharmacist in the country. 
For once we can truly say that the promise of ex- 
cellence hai been fu filled to the letter, and the Na- 



tional Dispensatory has come almost perfect from 
the hands of its makers. The entire work is a most 
excellent one, and cannot fail to satisfy the pur- 
chaser. We can conscientiously recommend it t) 
every student and practitioner of medicine and 
pharmacy. — St. Lov.i^ Clinical Record, Apr 1S79. 

This magnificent work has at last arrived, and 
we are at a loss for words to express our apprecia- 
tion and to give our readers an idea of it. The sub- 
je t-matter is brought to date, showing that it has 
been the unceasing aim of the authors to supply a 
much needed book, one that will contain all the im- 
portant facts, and not dwell upon points that are of 
com: aratively little interest to any but a specially 
interested student While this work, on account of 
its conciseness, is adapted to the pharniacal student, 
it is equally adapted to the medical student and 
practitioner by its well arranged therapeutical in- 
d<^x containing about 37,50 references, while the ma- 
teria medica index embraces about 10,400. The 
physician sees at a glance all medicines tha*^ are 
used for any certain class of disease. — Chicago Phar- 
macist and Chemist, April, 1879. 

It has been prepared by two gentlemen whose 
learning fully qualified them for the diflicult task,, 
and whose eminence entitles them to be heard with 
the respect and attention due to authority. The 
' raison d'etre'' of the book is modestly stated iit 
the preface, and now that it has been published and 
opens to us its vast stores of information, we may 
add that it was almost a necessity. — N. C Medic I 
Journ., March, 1S79. 



14 



Henry C. Lea's Publications — {Pathology^ &c.). 



no E NIL (F.), 

^ Pi'of. in the Faculty of Med. 



AND J?ANVIER (L.), 

Ports. Prof, in the College of France. 

MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
of Penna., and by Henry C. Simes. M.D., Demonstrator of Pathological Histology in 
the Univ. of Pa. In one very handsome octavo volume of about 700 pages, with over 
300 illustrations. {Shortly.) 

So much has been done of late years in the elucidation of pathology by means of the micro- 
scope, and this subject now occupies so prominenta position as one of the most important branches 
of medical science, that the American profession cannot fail to welcome a translation of the pre- 
sent work, wbich, through its own merits and through the well-known reputation of its distin- 
guished authors, is regarded in Europe as the standard text-book and work of reference in its 
department. Such investigations and discoveries as have been made since its appearance will be 
introduced by the translator, :ind the work is confidently expected to assume in this country the 
same position which has been so universally accorded to it abroad. 



JPENWIGK [SAMUEL), M.D., 

-*- Assistant Physician to the London Hospital.. 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo., cloth, $2 25. {Just Issued.) 



Of the m^ny gaide-bookg on medical diagnosis, 
claimed to be written for the special instruction of 
students, this is the best. The author is evidently a 
well-read audaccomplished physician. and he knows 
how to teach practical medicine. The charm of sim- 
plicity is not theleastint'^restingfeaturein theman- 
ner in which Dr. Fen wick conveys instruction. There 



are few books of this sizeon practical medicine that 
contain so much and convey it so well as c he volume 
before us. It is a book we can sincerely recommend 
to the student for direct instruction, a ad to the prac- 
titioner as a ready and useful aid to his memory. — 
Am. Journ. of Syphilography, Jan. 1874. 



G 



KEEN [T. HENRY), M.D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, etc. 

PATHOLOGY AND MORBID ANATOMY. Third American, from 

the Fourth and Enlarged and Revised English Edition. In one very handsome octavo 
volume of 332 pages, with 132 illustrations; cloth, $2 25. {Jiist Ready.) 



This is unquestionably one of the best manuals on 
the subject of pathology and morbid anatomy that 
can be placed in the student's hands, and we are 
glad to see it kept up to the times by new editions. 
Each edition is carefully revised by the author, with 
the view of makiug it include the most recent ad- 
vances in pathology, and of omitting whatever may 
have become obsolete. — N. Y. Med. Jour., Feb. 1879. 

The treatise of Dr. Green is compa-ct, clearly ex- 
pressFd, up to the times, and popular as a text-book, 
both in England and America. The cuts are suffi- 



ciently numerous, and usualiy well made. In the 
present edition, such new matter has been added as 
was necessary to embrace the later results in patho- 
logical research. No doubt it will continue to enjoy 
the favor it has received at the hands of the profes- 
sion. — Med. and Surg. Reporter, Feb. 1, 1879. 

For practical, ordinary daily use, this is undoubt- 
edly the best treatise that is offered to students of 
pathology and morbid anatomy. — Cincinnati Lan- 
cet and Clinic, Feb. 8, 1879. 



D 



AVIS [NATHAN S.), 

Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 

being acollection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royal 12mo. volume. Cloth, $1 75. {Lately Issued.) 



CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 213 large wood engravings. By R 
EoLESFiELD GRIFFITH, M.D. One vol. Svo., pp. 
1000, cloth. $4 00. 

CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liqcors in Health and Disease. Ne-w 
edition, with a Preface by D. F. Condte, M.D., and 
explanations of scientific words. In oneneatl2mo. 
volume, pp. 178, cloth. 60 cents. 

GLUGE'SATLAS OF PATHOLOGICAL HISTOLOGY 
Translated, with Notes and Additions, by J0(5EPH 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological. Etiological, and Thera 
peutical Relations. In two large and handsome 
octavo volumes of nearly 1.500 pp., cloth. $7 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. Svo. , pp.500, cloth. $3 50. 



BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condie, 
M D. 1 vol. Svo., pp 600. cloth. %2 50 

TODD'SCLINICAL LECTURES on CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pp., 
cloth. $2 50 

STURGES'S INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Being a Guide to the In- 
vestigation of Disease. In' one handsome 12m o. 
volume, cloth, ■$! 2.5. {Lately Issiied.) 

STOKES' LECTURES ON FEVER. Edited by John 
William Moore, M.D., Assistant Physician to the 
Cork Street Fever Hospital. In one neat Svo. 
volume, cloth, $2 00. {Just Lssued.) 

THE CYCLOPEDIA OF PRACTICAL MEDICINE: 
comprising Treatises on the Nature and Treatment 
of Diseases, Materia Medica and Therapeutics, Dis- 
eases of Women and Children, Medical Jurispru- 
dence, etc. etc. By Dcnglison, Forbes, Tweedie, 
and CoNOLLY. In' four large super-royal octavo 
volumes, of 3254 double-columned pages, strongly 
and handsomely bound in leather, $15; cloth, $11. 



Henry C. Lea's Publications — {Practice of 3Iedicine), 15 

pyLINT [AUSTIN], M.D., 

"*■ Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 
edition, revised and enlarged. In one large and closely printed octavo volume of about 
1100 pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. [Lately 
Issued. ) 
By common consent of the English and American medical press, this work has been assigned 
to the highest position as a complete and compendious text-book on the most advanced condi- 
tion of medical science. At the very moderate price at which it is offered it will be found one 
of the cheapest volumes now before the profession. 

This excellent treatii^e on medicine has acquired His own clinical studies and the latest contribu- 
foritselfintheUnited States a reputation similar to tions to medical literature both in this country and 
that enjoyed in lilngland by the admirable lectures in Europe, have received careful attention, so that 
of Sir Thomas Watson. We have referred to many some portions have been entirely rewritten, and 
of the most important chapters, and find the re^i- about seventy pages of new matter have been ad- 
sion spoken of in the preface is a genuine one, and ded. — C/iicn^ro M^d Jour., June, 1S73. 
thattheauthorhasvery fairlybrought uphismatter ' , , , 

to thelevelofthe knowledge of the present day. The Has never been surpassed as a text-book for stu- 
workhasthisgreatrecommendation.thatitisinone dents and a book of ready reference for practition- 
volume, and therefore will not be so terrifying to the ers The force of its logic, its simple and practicnl 



student as the bulky volumes which several of our 



teachings, have left it without a rival in the field 



Englishtext-booksofmedicinehavedevelopedinto. ^- Y.—Med. Record, Sept. 15, 1S74. 
— British and Foreign Med.-Ghir. Rev., Jan.lSlo It is given to very few men to tread in the steps of 

Itisofcourseunnecessarytointroduce or eulogize ! Austin Flint, whose single volume on medicinf, 
this now standard treatise. The present edition though hereand there defective, is a masterpiece (.f 
has been enlarged and revised to bring it up to the lucid condensation and of general grasp of an enor- 
author's present level of experience and reading, mously widesubject — Lond. Practitioner, I)ec.^l3- 

^Y THE SAME AUTHOR. 

CLINICAL MEDICINE; a Systomatic Treatise on the Diagnosis 

and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 £0. 
{Now Ready.) 
It has been the object of the author in this volume to present tbe science and art of medicine 
in their most practical aspect, adapted to the necessities of the student and physician in the 
daily routine of duties at the bedside. By avoiding the discussion of questions relating to 
pathology and etiology, spnce is gained for the thorough consideration of diagnosis and treat- 
ment, embracing many points which escape attention in the ordinary textbooks. In the arrange- 
ment of the work, disea.«es are classed according to the system of organs primarily affected ; and 
affections closely related are grouped together so as to elucidate their differentiation, and the 
appropriate treatment is pointed out for each. The preparation of the work has occupied the 
author for several years, and is presented a? embodying the results of prolonged observation and 
experience under opportunities more extensive than often fall to the lot of the physician. 

^ Y THE SAME A UTHOR 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. {J^cst Issued.) 

fJA R TSEORNE ( HEXR F) , M. D., 

-*■-*• Professor of Hygiene in the University of Pennsylvania 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDL 

CiNE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12mo volume, 
of about 550 pages, cloth, $2 63 ; half bound, $2 88. {Lately Issued.) 
Asa handbook, whichclearly sets forth the essen- i book, it cannot be improved upon. — Chicago Med. 
Ti.\LS of the PRiXGiPLES A.ND PRACTICE OF MEDICINE, Examiner, Xov. 15, 1874. 



do not know of its equal.— Va. Med. Monthly. 



Without doubt the best book of the kind published 



As a brief, condensed, but comprehensive hand- in the English language.— 5^ LoMZ6-ilfec/.a»(i Swrp. 

Journ., >iov. 1S74. 



W: 



'ATSON [THOMAS], M.D., ^c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Lately 
Published.) 

It is a subject for congratulation and for thank- cate and important pathological and practical ques- 
fuliessthat Sir Thomas Watson, during a period of tions, the results of his clear insight and his calm 
comparative leisure, after a long, laborious, and judgment are now recorded for the benefit of man- 
most honorableprofessional career, while retaining kind, in language which, for precision, vigor, and 
full possession of his high mental faculties, should classical elegance, has rarely been equalled^ and 
have employed the opportunity to submit his Lee- never surpassed The revision has evidently been 
tures to a more thorough revisionthan was possible most carefully done, and the results appear in al- 
during the earlier and busier period of his life, most every page. — Brit. Med. Journ., Oct. l-^ 1871. 
Carefully passingin review some of the most intri- ^ > • > 



IT) 



Henry C. Lea's Publications — {Practice of Medicine). 



nmSTO WE (JOHN SYER), M.D., F.R.C.F., 

J-) Physician and Joint Lecturfr on Medicine, St. Thoma.s-''s Hospital. 

A MANUAL ON THE PRACTICE OF MEDICINE. Edited, with 

Additions, by James H. Ilu chinson, M.D., Physician to the Penna. Hospital. In one 
handsome octavo volume of over 1100 pages : cloth, $5 50 ; leather, $6 50. (Just Issued.) 



This portly volume is a model of condensation. 
In a style at once clear, interesting, and concise, Dr. 
Bristowe passes in review every conceivable subject 
connected with the practice of medicine. Those 
practitioners who purchase few books will find this 
a mott opportune publication, because to many top- 
ics not usually emb'ace<i in a work on practice are 
adequaiely handled. The book is a thoroughly good 
one, and its usefulness to American readers has heen 



incrensed by the judicious notes of the Editor. — 
Cincinnati Clinic, Jan 7, 1877. 

Anyone who wants a good, clear, condensed work 
upon Practice, quite up with the mostrecent views in 
pathology, will find this a most valuable work. The 
additions made by Dr. Hutchinson are appropiiate 
and useful, andso well done that we wisli there were 
more of them. — Am. Practitioner, Feb. 1S77. 



ViroODBURY [FRANK], 31. D., 

Phy.tician to the Germa.n Hotpital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College 
Hospital, etc. 

A HANDBOOK OF THE PPvINCIPLES AND PRACTICE OF 

Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook 
of Practice. In one neat volume, royal 12mo. {In Press.) 



fJABERSHON [S. 0.) M.D. 

■JlJL Senior Physicinn to and late Lecturer on the Principles and Practice of Medicine at Guy's 

Hospital, etc. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Canal, GEsophagus, Caecum, Intes- 
tines, and Peritoneum. Second American, from the third enlarged and revised Eng- 
lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 

Cloth, $3 50. {Now Ready.) 

This work has remained s n)e time out of print, owing to the careful and conscientious 
revision which it has enjoyed at the hands of the author, and which has nearly doubled its 
size since the appearance of the first edition. Yet there is no work accessible to the profession 
to take its place, as a careful, practical guide on a class of diseases, which form so large and 
important a portion of the duties of the physician, and for which the author's position has 
given him almost unequalled opportunities for observation and experience. 



We can do very little to add to the favorable re- 
ception which has already been given by the m.edi- 
cal pre.ss of the world to this well known treatise 
We CO'! mend to all practitioners a careful perusal 
of Dr H -, bershon's w irk More especially, wedraw 
attention to the number of intestinal diseases re- 
corded in its pages, cases of extreme interest clini- 
cally and pathologically. This careful record shows 
that the work is no compilation, but a careful exposi- 
tion of the author's personal experience. — Canadian 
Med. and Surg. Journ., May, 1879. 

As a work of reference, as well as daily study, no 
work yet emanating from the medical press is 
worthy of more careful consideration by the general 
practitioner than the above. With the careful re- 
visinu given this edition, Dr. Habershon's work 
will still remain at the head of the list, and con 
tinue to be regarded as one of the best treatises on 
abdominal diseases extant — South. Practitioner. 
June, 1879. 

There have been many laborers in this depart- 
ment of special pathology, and among them no one 
has done better service than Dr. Habershon. The 
first editions were exhausted long since, and the 
author has i-evisedthe one now under consideration 



with great care and thoroughness. The chapters on 
constipation and intestinal obstruction are of high 
value, and are worth many times the cost of the 
book, which, altogether, is a most excellent one. — 
St. Louis vlin. Record, June, 1879. 

This valuable treatise on diseases of the stomach, 
and abdomen has been out of printfor several years, 
and is therefore not so well known to the profession 
as it deserves to be. It will be found a cyclopsedia 
of information, systematically arranged, on all dis- 
eases of the alimentary tract, from the mouth to the 
rectum A fair proportion of each chapter is devot- 
ed to symptoms, pathology, and therapeutics. The 
present edition is fuller tnan former ones in many 
particulars, and has been thoroughly revised and 
amended by the author. Several new chapters have 
been added, bringing the wo'-k fully up to the times, 
and making it a volume of interest to the practitioner 
in every field of medicine and surgery. Perverted 
nutrition is in some form associated with all diseases 
we have to combat, and we need all the light that 
can be obtained on a subject so broad and general. 
Dr Habershon's work is one that every practitioner 
should read and study for himself. — N. Y. Mtd, 
Journ., April, 1S79. 



F 



'OTHERGILL {J. MILNER),M.D. Ediv., M.R.C.P. bond., 

Asst. Phys. to the West Lond Hosp. : As.<tt. Phy.s-. to the City of Lond. Hosp.,etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the 

Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, 

$4 00. {Now Ready.) 

he knew how suggestive and helpful it would be to 
him.— A"?. Louis Med. and Surg. Journ , April, 1877. 

We heartily commiMid bis book totheniedicalstudent 
as an honest and intelli|ient guide through the mazes of 
therapeutics, and assure the practitioner who has grown 
gray in the harness that be will derive pleasure and in- 
struction from its perusal. Valuable suggestions and 
material for thought abound throughout.- Boston Med. 
and Surs: Journal, Mar 8, 1877. 



Our friends will find this a very readable book ; and 
that it sheds ligbi upon every theme it touches, causing 
the practitioi.er to feel more certain of his diagnosis in 
difficult cases. We confidently commend the work to 
our readers as one worthy of careful perusal. It lighis 
the way over ooscure and difiicult passes in medical 
practice. The chapter on the circulation of the blood 
is the most exhaustive and instructive to be found. It 
is a book every practitioner needs, and would have, if 



JDY THE SAME AUTHOR. 

THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT 

IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal 
12mo. of 156 pages; cloth, $1 00. {Just Ready.) 



i 



Henry C. Lea's Publicatioxs — {Diseases of the Skin^ So.). IT 
'REYNOLDS [J. RUSSELL), M.D., 

J-^ Prof, nf the Principles and Practice of Medidne in Univ. College, London. 

A SYSTE>[ OF MEDICINE with Notks and A^ddittoks by Hi^-nry Harts- 
HORNE, M.D., late Professor of Hygiene in the University of Penna. In three large and 
hnndsorae octavo volume?, containin? about 3000 closely printed double-columned pages, 
with numerous illustrations. {Li Press ) 

Volume I. {nearly ready) contains General Diseases and Diseases of the Neryotjs System. 

VoLUMK II. {shortly) will contain Diseases of the Respiratory and Circulatory Systems. 

YoLUjrE III. {prepariny for early publi rati 07i) will contain Diseases of the Digestive and 

Blood Glandular Systems, of the Urinary Organs, of the Female Reproductive 

System, and of the Cutaneous System. 

Reynolds's System of Medicine, recently completed, has acquired, since the first appearance 
of the first volume, the well-deserved reputation of being the work in which modern British 
medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
view of the fact that it is the result of the collaboration of the leading minds of the profession, 
each subject being treated by some gentleman who is regarded as its highest authority — as for 
instance. Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
eases of the Spine by Chari.es Bland Radcliffe, Pericarditis by Francis Sibson, Alcoholism 
by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde Salteb, 
Cerebral Affections by ri. Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson 
Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
fenzie. Diseases of the Rectum by Blizard Cdrling, Diabetes by Lauder Brcnton, Intes- 
tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- 
bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain 
have contributed their best men in generous rivalry, to build up this monument of medical sci- 
ence. St. Bartholomew's, Guy's, St Thomas's, University College, St Mary"s in London, while 
the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical 
School at Netley, the military and naval services, and the public health boards. That a work 
conceived in such a spiri% and carried out under such auspices should prove an indispensable 
treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
the success which it has enjoyed in England, and th'e reputation which it has acquired on this 
side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 

Its large size and high price having kept it beyond the reach of many practitioners in this 
country who desire to possess it, a demand has arisen for an edition at a price Avhich shall ren- 
deij^it accessible to all. To meet this demand the present edition has been undertaken. The 
five volumes and five thousard pages of the original will, by the use of a smaller type and double 
columns, becompres-ed into three volumes of about three thousand pages, clearly and hand- 
somely printed, and offered at a price which will render it one of the cheapest works ever pre- 
sented to the American profession. 

But not only will the American edition be more convenient and lower priced than the English ; 
it will also be better and more couiplete. Some years having elapsed since the appearance of a 
portion of the work, additions will be required to bring up the subjects to the existing condition 
of .science. Some diseases, also, which are comparatively unimportant in England, require more 
elaborate treatment to adapt the articles devoted to them to the wants of the American physi- 
cian ; and there are point? on which the received pra3tice in this country differs from that 
adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- 
horne, M.D., late Professor of Hygiene in the University of Pennsylvania, who will endeavor 
to render the work fully up to the day, and as useful to the Amerif^an physician as it has proved 
to be to his English brethren. The number of illustrations will also he largely increased, and 
no effort will be spared to render the typographical execution unexceptionable in every respect. 
The first volume containing more than 1100 paees, is now on the ev'^ of publication. Volume 
II. is fir advanced in preparation, and the completion of the whole may be expected before the 
close of the year. 



^OX ( TILBURF}. M.I)., F.R.C.P., and T. C. FOX, B.A., M.R.C.S., 

Physician to the De.partme.ni for Skin Diseases, University College Hospital. 

EPITOME OF SKIX DISEASES. WITH FORMULA. For Stu- 

DENTS AND PRACTITIONERS. Second edition, thoroughly revised and greatly enlarged. In 
one very handsome 12mo. volume of 216 pages. Cloth, $1 38. {Just Ready.) 
The names of the authors are quite sufiB-ietit to ' exceeds in size, and surpasses in use, it? predeces- 
comni^nd this book, Dr. Tilbury Fox beirg we^l sor. The work is certainly a valuable addition to 
koowu as occupying a place in the front rank or the '• hnndy volume" department of medical litera- 
derm;t^ologists of the ^2ij.— Gana<iian Journal of tnre.— The Med. Bulletin, May, 1S7S 
Med. Sri., May, 1^7S. p^^. stQ^ents a better book was never devised.— 

The present edition of the Epitome considerably Cincinnati Lancet and GUnic, May, 1S79. 



WILSON'S STUDENT'S BOOK OF' CUTANEOUS HILLIER'S HANDBOOK OF SKIN DISEASES, for 
MEDICINE and Diseases of the Skin. Iu one Students and Fraciitioners. Spcond Am Ed.' In 
very handsome royal 12mo volume. $3 oO. one roval 12mo. vol of 3oS pp. With illustrations 

, Cloth, $2 25. 



18 Henry C. Lea's Publications — {Practice of Medicine^ &c.). 



piNLAYSON [JAMES], M.D., 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac 

titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra 

tions. Cloth, $2 63. {Jnst Ready.) 
The book is an excellent one, clear, concise, conve- This is one of the really useful books. It is attrnc 
nient, practical. It is replete with the very know- tive from pn-face to the final page, and ought to be 
ledge the student needs when he quits the lecture- given a place on every office tabl 
room and the laboratory for the ward and sick-room, 
and does not lack in information that will meet the 



wants of experienced and older men.— Phila. Med. 
Times, Jan. 4, 1879. 

The aim of the author is to teach a student and 
practitioner how to examine a case so as to ns^e ^^all 
his knowledge^' in arriving at a diagnosis. All the 
various symptoms of the several systems are grouped 
together in such a manner as to make their relations 
to a final diagnosis clear and easy of apprehension. 
This work has been done by men of large experience 
and trained observation, who have been long recog- 
nized as authorities upon the subj. cts which they 
treat. There is a profusion of illustrations to illus- 
trate subjects under discussion. The application of 
electricity, and instruments of precision in diagnosis, 
is fully discussed. This book is all good. We com- 
mend it to all students and practitioners of medicine 
as a work worthy of a place in their libraries. — Ohio 
Med. Recorder, Dec. 1878. 



because it contains 
in a condensed form all that is valuable in semeiology 
and diagnostics to be found in bulkier volumt^s, and 
because in its arrangement and complete index, it is 
unusually convenient for quick reference in any 
emergency that may come upon the busy practitioner. 
—N. Q. Med. Journ., Jan. 1879. 

This is a most important work for students, and 
one that is dtstined to become rnpidly popular. It 
is composed of contributions from various eminent 
sources bearing upon this subject. The real secret 
of successful practice is the accurate diagnosis of 
disease. This manual teaches the student to arrange 
his investigation in such system as to enable him, 
with practice, to acquire this very desirable faculty. 
The division of the subject, as in this work, among 
the highest authorities living, is a good idea, and 
gives us in one compact form a series of monographs 
written by mdinier a. —Nashville Journal of Mtd. 
and Surg., Jan. 1879. 



TJAMILTON [ALLAN McLANE), M.D., 



Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelV s Mand, N. Y., 
and at the Out- Patients'' Department of the New York Hospital. 

NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. 

In one handsome octavo volume of 512 pages, with 53 illua. ; cloth, $3 50. {Just Ready.) 



This is unquestionably the best and most com 
plete text-book of nervous diseases that has yet ap- 
peared, and were international jealousy in scien^ifio 
afi'airs at all possible, we might be excused for a 
feeling of chagrin that it should be of American 
parentage. This work, however, has been performed 
in New York, and has been so well performed that 
no room is left for anything but commendation. 
With great skill. Dr. Hamilton has presented to his 
readers a succinct and lucid survey of all that is 
known of the pathology of the nervous system, 
viewed in the light of the most recent researches. 
From the preliminary description of the methods of 
examination and study, and of the instruments of 
precision employed in the investigation of nervous 
diseases, up till the final collection of formulse, the 
book is eminently practical. — Brain, London, Oct. 
1878. 

The author tells us in his preface that it has been 
his object to produce a concise, practical book, and 
we think he has been successful, considering the ex- 
tent of the subject which he has undertaken. In 
fact, it is more extensive than the title properly or 
accurately indicates, embracing— besides what are 
usually regarded as nervous diseases — inflammatory 
afi'ections, both acute and chronic, hemorrhages and 
tumors of the cerebrum and cerebellum, medulla 
oblongata, spinal cord and nerves, with thrombosis 
and embolism of the arteries, sinuses, and veins. 
The reader may therefore expect information, more 
or less fall and satisfactory, on almost every roint 



connected with the nervous system. We have no 
hesitation in saying that reliance may be placed on 
Dr. Hamilton's conscientious performance of his sell- 
assigned task, on his soundness of judgment, and 
freedom from empiricism. — Edinburgh Med. Journ., 
Oct. 1878. 

From a very careful examination of the whole 
work, we cat justly say that the author has not only 
clearly and fully treated of diagnosis and treatm*lnt, 
but, unlilit^ most works of this class, it is very com- 
prehensive in regard to etiology, and exposes the 
pathology of nervous diseases in the light of the very 
latest experiments and discoveries. The drawingss 
are excellent and well selected. After this careful 
revision, we can heartily recommend this work to 
student-i and general practitioners in particular as 
being a full exposition of aiseases of the nervous sy.>-. 
tem, their pathology and treatment, to date. — xV. Y. 
Med. Record, Aug. 3, 1878. 

As stated in the preface, the author's object has 
been to write a concise and practical book, for 
which there is certainly a place, and we think he 
has succeeded admirably in fulfilling his object. 
The Uk^ual plan is adopted in the clas.«ification of 
the difi'erent diseases, the book not being greatly 
unlike Hammond's in this respect, although it is 
very noticeable throughout that the author's opin- 
ions vary widely from those of Dr Hammond. — Am. 
Supp. Obstet. Journ. Great Britain and Ireland, 
July, 1878. 



(IHARCOT [J. M.), 

Professor to the Faculty of Med. Paris, Phys. to La Salpetri^re, etc. 

LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- 
lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, 
etc., Cath. Univ. of Ireland. With illustrations. 1 vol. 8vo. {Tn December.) 



CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS ByC. Handfield Jones, 
M.D., Physician to St. Mary's Hospital, &c. Sec 
ond American Edition. In one handsome octavo 
■volume of 8-18 pages, cloth, -f.3 2,5 

CHAMBERS'S MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome 
octavo volume. Cloth, $2 75 

LINCOLN'S ELECTRO-THERAPEUTICS; a Concise 
Manual of Medical Electricity. In one very neat 



royal 12mo. volume, cloth, with illustrations, 
$1 50. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION ; its Disorders and their Treatment. 
From the second London edition. In one hand- 
some volume, small octavo, cloth, $2 00. 

PAVY'S TREATISE ON FOOD AND DIETETICS. 
Physiologically and Therapeutically Considered. 
In one handsome octavo volume of nearly 600 
pages, cloth, $4 75. 



Henry C. Lea's Publications — {Diseases of the Chest, &c.). 



19 



JDROWN [LENNOX), F.R.G.S. Ed., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc., 

THE THROAT AND ITS DISEASES. With one hundred Typical 

Illustrations in colors, and fifty wood engravings, designed and executed by the author. 
In one very handsome imperial octavo volume of 351pages ; cloth, $5 00. {Now Ready.) 



The author's rare artistic skill has been utilized 
in the production of one hundred beautiful illustra- 
tions in colors, the very best of the kind we have 
seen, and which have been distributed in ten plates. 
Fifty wood engravings, designed and executed by 
the author, appear in the body of the work — these 



are unusually accurate. In conclusion, we recom- 
mend this beautiful volume as an acceptable addi- 
tion to the library of those engaged in the treatment 
of dist^ases of the throat. — N. Y. Med. Record Nov. 
9, 1S78. 



OEILER {CARL), M.D., 

O Lecturer on Laryngoscopy at the Univ. of Penna. , Chief of the Throat Dispensary at the 

Univ. Hospital, Phila., etc. 

HANDBOOK OF DIAGNOSIS AND TREATiMENT OF DISEASES OF 

THE THROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume, 
of 156 pages, with 35 illustrations; cloth, $1. (Jicst Ready.) 

The intention of the author expressed in the pre- 
face to make this little book " serve as a guide to 
students of laryngoscopy in acquiring the skill re- 
quisite to the successful diagnosis and treatment of 
diseases ot the larynx and naso-pharynx" has been 
most ably carried out. We most heartily commend 
this book as showing sound judgment in practice, 
and perfect familiarity with the literature of the 
specialty it so ably epitomizes. — Philada. Mtd. 
Times, July 5, 1879. 

We can heartily commend this volume to the med- 
ical student as a good guide to the study of laryn- 
goscopy and rhinoscopy penned by the land of a 



sntleman fully familiar with the subject of which 
he writes.— iV^. Y. Med. Record, July 19, 1879. 

A convenient little handbook, clear, concise, and 
accurate in its method, and admirably fulfilling its 
purpo.^e of bringing the subject of which it treats 
within the comprehension of the general practi- 
tioner.— iV^. 0. Med. Jour., June, 1879. 

The author has produced a most useful book, as 
clear and reliable as it is concise. For use in con- 
nection with clinical study this little work will 
l)rove trustworthy and convenient.— i>e^?'oi^ Lan- 
cet, Aug. 1879. 



J^LINT [AUSTIN), M.D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 

ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume : $3 50. (Lately Issued.) 
This book contains an analysis, in the author's lucid I mend the book to the perusal of all interested in the 

style, of the notes which he lias made in several hun- .study of this disease. — Boston Med. and Surg . Journal, 

dred cases in hospital and private practice. We com- 1 Feb. 10, 1876. 

DY THE SAME AUTHOR. 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In 
one handsome royal 12mo. volume : cloth, $1 75. (Just Issued.) 



JDY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 

edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 

Dr. Flint chose a difficult subject for his researclie-, • iad clearest practical treatise on those subjects, and 

and has shown remarkable powers of observHiion J should be in the hands of all practitioners and stu- 

and reflection, as well as great industry, in his treat- lents. It is a credit to American medical literature. 

ment of it. His book must be considered the fullest | —Amer. Journ. of the Med. Sciences, July, 1860. 

F THE SAME AUTHOR. 

A PRACTICAL TREATISE OX THE PHYSICAL EXPLORA- 
TION OP THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 695 pages, cloth, $4 50. 

LA ttOCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 
of .^00 pages Price, S3 00. 



B 



WILLIAMS S PULMONARY CONSUMPTION; its 
Nature, Varieties, and Treatment. With an An- 
alysis of One Thousand Cases to exemplify its 
duration. In one neat octavo volume of about 
350 pages; cloth, $2 50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one neatroval 12mo. volume, cloth, 
$1 25. 

WALSHE ON THE DISEASES OF THE HEART AND 
GREAT VESSELS. Third American Edition. In 
1 vol. Svo., 420 pp., cloth, $3 00. 

LECTURES ON THE DISEASES OF THE STOMACH. 
With an Introduction on its Aaatomy and Physio- 
logy. By William Brinton, M.D., F.R.S. From 
the second and enlarged Londonedition. With il- 
lustrations on wood. In one handsome octavo 
volume of about 300 pages: cloth, $3 26. 



FULLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical Diagnosis, 
Symptoms, and Treatment. From the second and 
revised English edition. In one handsome ocatvo 
volume of about 500 pages : cloth, $3 50. 

SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. Svo. , pp. 254 $2 2.'^. 

BASHAM ON RENAL DISEASES : a Clinical Guide 
to their Diagnosis and Treatment. With Illustra- 
tions. In one 12mo. vol. of 304 pages, cloth, $2 OO. 

LECTURES ON THE STUDY OF FEVER. By A. 

HuDSOif, M.D., M.R.I. A., Physician to the Meath 

Hospital. In one vol. 8vo., cloth, $2 50. 
A TREATISE ON FEVER. By Robert D. Lyons, 

K C C. In one octavo volume of 362 pages, clotb, 

$2 25. 



20 



Henry C. Lea's Publications — {Venereal Diseases, &c,). 



jyUMSTEAD {FREEMAN J.), M.D.,LL.D., 

•*-^ Professor of Venereal Diseases at the Ool. of Phys. and Surg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Fourth edition, 
rerised and largply rewritten with the co-operation of R. W. Taylor, M.D., of New 
York, Prof, of Dermatology in the Univ. ff Vt. In one large and handsome octavo 
volume of over 800 pages, with numerous illustrations. {Freparing.) 
This work, on its first appearance, ira mediately took the position of a standard authority on 
its subject wherever the language is spoken, and the success of an Italian translation shows 
that it is regarded with equal favor on the Continent of Europe. In repeated editions the author 
labored sedulously to render it more worthy of its reputation, and in th<^ present revision no 
pains have been spared to perfect it as far as possible. Several years having elapsed since 
the publication of the th'rd edition, much material has been accumulated during the interval 
by the industry of syphilologists, and new views have been enunciated. All this so far as 
confirmed by observation and experience, has been incorporated; many portions of the volume 
been rewritten, the series of illustrations has been enlarged and improved, and the whole may 
be regarded rather as a new work than as a new edition. It is confidently presented as fully on 
a level with the most advanced condition of syphilology, and as a work to which the practi- 
tioner may refer with the certainty of finding clearly and succinctly set forth whatever falls 
within the scope of such a treatic:e. 



c 



ULLERIER [A.), and 

Surgeon to the Hdpital du Midi 



J?UMSTEAD {FREEMAN J.), 

-^-^ Professor of Venereal Diseases in the College of 
Physicians and Surgeons, N. Y 



AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bomstead. In one large'imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of 
practice. Gentlemen desiring early impressions of the plates would do well to order it without 
delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. 

We wish for once that our province was not re- 
stricted to methods of treatment, that we might say 
something of the exquisite ctdored plates in this 
volume. —London Practitioner, May, 1869. 

Other writers besides M. Cullerier have given ass 
good account of the diseases of which he treats, bu: 



of illustrations of the venereal diseases. There is. 
however, an additional interest and value poi-sesst d 
by the volumebefore us; for it is an American reprint 
and translation of M CuUerier's work, with inc:- 
dental remarks by one of the most eminent Ameri- 
can syphilographers, Mr. Bumstead.— -Brif .awciFo' . 



no one has furnished us with such a complete series i Medico-Chir. Review, July, 1869. 



LEE'S LECTURES ON SYPHILIS >ND SOME 
FORMS OF LOCAL DISEASE AFFECTING PRIN- 
CIPALLY THE ORGANS OF GENERATION. In 
one handsc me octavo volume ; cloth, $2 2"). 



HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS In one handsome octavo volume ; 
cloth, .$3 25. 



w 



EST { CHARLES), M. />., 

Physician to the Hospital for Sick Children, London, *c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILI- 

HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Late/7/ Isstted ) 

clas-ical book of a great and model physician. Few 
have Ihe opportnni.ies of Dr. West for observatior, 
and fewei' still the peculiar powers necessary for 
^ucces>fully ftudyiug t^ e diseases of children. We 
pre.>-uroe that few aedical libraries of a dozen vol- 
umes are without the above work. This is true, 
priacipally, because it is indispensable to every 
general practitioner. — Detroit Rtv. of Med. and 
Fharm., June, 1874 



Of all the English writers on the diseases ol chil- 
drea, there is no one so entirely satisfactory to us 
as Dr. West. For years we have held his opinion 
as iiidicia". ard have regarded him as one of the 
highest living authorities in the difficult department 
of medical science in which he is most widely 
known - Bn.<ifon Med. and f^nrg. Journal 

No medical student can afford to be without this 



-DY THE SAME AUTHOR. [Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
London, in March, 1871. In one volume small l2tno., cloth, $1 00. 

-nY THE SA'fE AUTHOR. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 650 pages, clotl , 
$3 75; leather, $4 75. 



CONDIE'S PRACTICAL 'TREATISE ON THE DIS- 
E\SES OF CHILDREN. Sixth edition, revised 
and aucmented. In one large octavo volume of 
i3e.^rly 8'0 closely ., riuted pa^es, cloth, ^o 25; 
jr $3 25. 



SMITH'S PRACTICAL TREATISE ON THE WAST- 
ING DISEASES OF INFANCY AND CH.LDHOOD. 
Second American, from the second revised atd 
enlarged Ea^lish edition. In ont handsome octa- 
vo voiume, cloth, $2 50. 



Henry C. Lea's Publications — (Diseases of Children, &c.). 21 



S 



MITH[J. LEWIS), M.D., 

Clinical ProfHS-for nf Diseases of Children in the Bellevue Hospital Mtd. College, N T. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Fourth Edition, revised nnd enlarged. In one handsome octavo volume 
of about 750 pages, with illustrations. Cloth, $4 50 ; leather, $5 50. {No^v Ready.) 

The very marked favor with which this work has been received wherever the English lan- 
guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spnre 
no pains in the endeavor to render it worthy in every respect of a continunnce of professiouiil 
confidence. Many portions of the volume have been rewritten, and much new matter iniro 
duced, but by an earnest effort at condensation, the size of the work has not been materially 
increased. 

In the period which has elapsed since the third 
edition of the woik, so extensive have been the ad- 
vances that whole ihapters required to be lewiittea, 
and hardly a page con'd pass without some material 
correction or addition. This labor has occupied the 
writer closely, and he has performed it conscieu- 
tioasly, so that the book may be considered a faith- 
ful portraiture of an exceptionally wide clinical 
experience in infantile diseases, c rrected by a care- 
ful study of the recent literature of the subject.— 
Med. and Surg. Reporter, April 5, 1879. 

It is scarcely necessary for us to say the work be' 
fore us is a standard work upon diseases of children, 
and that no work has a higlier standing than it upon 
those affections. In consequence of its thorough re- 
vision, the woik has been made of more value than 

ever, and may be regarded as fully abreast of the ._.. 

times. We cordially commend it to students and ' nently the authority upon diseases of childi 



This excellent work is f^o well known that an 
ex ended notice at this time would be superfluous. 
The author has taVen advantage of the demand for 
another new ei it on to revise in a most caretul 
manner the entire book ; and the numerous correc- 
tions and additions evince a determination on his 
part to keep fully abreast with the rapid progress 
that is being m^^de in the knowledge and treatment 
of children's diseases By the adoption of a s me- 
what clo-er type, an increase in .size of only chirty 
pa^es has been necessitated by the new subject 
matter introduced.— -B-^sfon, Med. and Surg. Jour , 
May 29, 1S79. 

Probably no other work ever published in this 
country upon a medical subject has reached such a 
heighth of popuUrity as has this well-known trea- 
'se. As a text and reference-book it is preemi- 

It 



physicians. Therrt is no better work in the language 
on di.seases of children. — Cincinnati Med. Ntws, 
March, 1879. 

1 he author has evidently determined thatit shall 
not lose ground in the esteem of the profession for 
want of the latest knowledge on that important 
department of medicine. He has accordingly in- 
corporated in the present edition the useful and 
practical re iults of the latest study and experience, 
b"th American and foreign, especially those bearing 
on therapeutics. Altogether the book has been 
greatly improved, while it has not been greatly 
increased in size. — New York Mtdical Journal, 
June, 1879. 



tands deservedly higher in the estimation of the 
profession than any other work upon the same sub- 
ject.— A'a.s/^^•^Z/6 Journ. of Med. and Surg., Way, 
1879. 

The author of this w.irk has acquired an immense 
experience as physician to three of the large char- 
ities of New York iu which children are treated. 
These asylums afford unsurpassed opportunities for 
observing the effects of different plans of treatment, 
and the lesults as emb idied in this volume may be 
accepted with faith, and should be iu the possession 
of all practitioners n^w, in vi^ w of the approaching 
season whtu the diseases of children always increase. 
—Nat M^.a. Rtvitw, April, 1879. 



Jg WAYNE [JOSEPH GRIFFITHS), M.D., 

Physician- Accouehei(.r to the British Gt-nernl Hn.^pitnl. &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE Second American, from the Fifth and Revised 
London Edition with Additions by E. R. Hutchins, M.D. With Illustrations. In one 
neat 12mo volume. Cloth, $1 25. ( Lately Issued.) 
*^* See p. 4 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the " American Journal of the Medical Sciences." 



CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIARTO WOMEN. 1 vol. 
"^vo. , pp 4;)(), cloth $2 .-iO. 

DEWEES'S TREATISE ON THE DISEASES OF FE- 
MALES. With illustrations. Eleventh Edition 
with the Author's lastimprovementsand correc- 
tions. In one octavo volume of .5.36 pages, with 
plates, cloth. $3 00. 



MEIGS ON THE NATURE, SIGNS. AND TREAT- 
MENT OF CHILDBED FEVER 1 vol. B\o , pp. 

36.5. cloth $2 i;0. 

ASH WELL'S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third andrevised London edition. 1 vol. 
8vo., pp. 528, cloth. -$3 50. 



J^ODOE [HUGH L.), M.D., 

Emeritus Professor of Obstetrics, &c., in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN ; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 

Professor Hoage's wura ib truly an originai one I contribution tothe study ofwomen'Fdi.-eases.itis rf 
from beginning to end, consequently no one can pe- great value, and is abundantly able to stand on its 
ruse its pages without learning something new. Asa | own merits. — N Y. Medical Record. Sept. 16, 18t.>. 

BURGHILL [FLEETWOOD), M.D., M.R.I.A. 
ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additior s 
by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- 
dren," &c. With one hundred and ninety four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00 ; leather, %b 00. 

MONTGOMERY'S EXPOSITION OF THE SIGNS | RiQBT'b SYSTEM OF MIDWIFERY. With notes 
A.ND SYMPTOMS OF PREGNANCY. With two I and Additional illustrations. Second Ameri«an 
exqnisitecoloredplates, and numerouswood ents. edition. One volume octavo, cloth 422 pages, 
In 1 vol.8vo..ofnearly600pp.,clotb,$3 75. I $2 50. 







22 



Henry C. Lea's Publications — (Diseases of Women). 



ffHOMAS {T.GAILLARD),M.D., 

^ Professor of Obstetrics, &c., in the College of Physicians and Sttrgeons, N. T., &c 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 

800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 

The author has taken advantage of the opportunity afforded by the call for another edition of 

this work to render it worthy a continuance of the very remarkable favor with which it has been 

received. Every portion has been subjected to a conscientious revision, and no labor has been 

spared to make it a complete treatise on the most advanced condition of its important subject. 

is classical without being pedantic, full in the details 
of anatomy and pathology, without ponderous 
translation of pages of German literature, describes 
distinctly the details and difficulties of each opera- 
tion, without wearying and useless minutiae, and is 
in all respects a work worthy of confidence, justify- 
ing the high regard in which its distinguished au- 
thor is held by the profession. — Am. Supplement, 
Obstet.Journ., Oct. 1874. 



A work which has reached a fourth edition, and 
that, too. in the short space of five years, has achieved 
a reputation which places it almost beyond the reach 
of criticism, and the favorable opinions which we have 
a'ready expressed of the former editions seem to re- 
quire that we should do little more than announce 
this new issue. We cannot refrain from saying that, 
as a practical work, this is second to none in the Eng- 
lish, or. indeed, in any other language. The arrange- 
ment of the contents, the admirably clear manner in 
which the subject of the differential diagnosis of 
several of the diseases is handled, leave nothing to be 
desired by the practitioner who wants a thoroughly 
clinical work, one to which he can refer in difficult 
cases of doubtful diagnosis with the certainty of gain- 
ing light and instruction. Dr. Thomas is a man with a 
very clear head and decided views, and there seems to 
be nothing which he so much dislikes as hazy notions 
of dia-znosis and blind routine and unreasonable thera- 
peutics. The student who will thoroughly study this 
b 3ok aUjd test its principles by clinical observation, will 
certainly not be guilty of these faults. — London Lancet, 
Feb. 13, 1875, 

Reluctantly we are obliged to close this unsatis- 
factory notice of so excellent a work, and in conclu- 
eiou'would remark that, as a teacher ofgyna;cology, 
both didactic and clinical, Prof. Thomas has certainly 
taken the lend far ahead of his confreres, and as an 
author he certainly has met with unusual and mer- 
ited Kuccef-!S.— ^m Journ. of Obstetrics, Nov. 1874. 

This volume of Prof. Thomas in its revised form 



ProfessorThomasfairly took the Profession of the 
United States by storm when his book first made its 
appearance early in 1S68. Its reception was simply 
enthusiastic, notwithstanding a few adverse criti- 
cisms from our transatlantic brethren, the first large 
edition was rapidly exhausted, and in six mouths a 
second one was issued, and in two years athird one 
was announced and published, and we are now pro- 
mised the fourth. The popularity of this work was 
not ephemeral, and itssuccess wasunprecedentedin 
the annalsof American medical literature. Six years 
is a long period in medical scientific research, but 
Thomas's work on " Diseases of Women" is still the 
leading native production of the United States. The 
order, the matter, the absence of theoretical disputa 
tiveness, the fairness ofstatement, and the elegance 
of diction, preserved throughoutthe entire range of 
the book, indicate that Professor Thomas did not 
overestimate his powers when he conceived the idea 
and executed the work of producing a new treatise 
upon diseases of women. — Prof. Fallen, in Louis- 
ville Med. Journal, Sept. 1874. 



T?ARNES [ROBERT], M.D., F.R.C.P,, 

-*-' Obstetric Physician to St. Thomas's Hospital, &-c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In one handsome octavo volume, of 784 pages, with 181 illustrations. 
Cloth, f 4 60 ; leather, $5 60. {Just Ready.) 

The call for a new edition of Dr. Barnes's work on the Diseases of Females has encouraged 
the author to make it even more worthy of the favor of the profession than before. By a rear- 
rangement and cnreful pruning space has been found for a new chapter on the Gynsecological 
Relations of the Bladder and Bowel Disorders, without increasing the size of the book, while 
many new illustrations have been introduced where experience has shown them to be needed. It 
is therefore hoped that the volume will be found to reflect thoroughly and accurately the present 
condition of gynaecological science. 



Dr Barnes stands at the head of his profession in 
the old country, and it requires but scant scrutiny 
of his book to show that it has been sketched by a 
master. It is plain, practical common sense ; shows 
very deep research without being pedantic ; is emi- 
nently calculated to inspire enthusiasm without in- 
culcating rashness; points out the dangers* to be 
avoided as well as the success to be achieved in the 
various operations connected with this branch of j 
medicine; and will do much to smooth the rugged 
path of the young gynsecologist and relieve the per- 
plexity of the man of mature years. — Canadian 
Journ. of Med. Science, Nov. 1878. 

We pity the doctor who, having any consider- 
able practice in diseases of women, has no copy of 
" Barnes" for daily consultation and instruction. It 
is at once a book of great learning, research, and 
individual experience, and at the same time emi- 
nently practical. That it has been appreciated by 
the profession, both in Great Britain and in this 
country, is shown by the second edition following 
so soon upon the first. — Am. Practitioner, Nov. 
187S. 

Dr Barnes's work is one of a practical character, 
largely illustrated from cases in his own experience, 
but by no means confined to such, as will be learned 
from the fact that he quotes from no less than 628 
medical authors in numerous countries. Coming 
from such an author, it is not necessary to say that 



the work is a valuable one, and should be largely 
consulted by the profession. — Am. Svpp Obstetrical 
Journ. Gt. Britain and Ireland, Oct. 1878. 

No other gynecological work holds a higher posi- 
tion, having become an authority everywhere in 
diseases of women. The work has been brought 
fully abreast of present knowledge. Every practi- 
! tioner of medicine should have it upon the siielves 
of his library, and the student will find it a superior 
text-book. — Cincinnati Med. News, Oct. 1878. 

This second revised edition, of course, deserves all 
the commendation given to its predecessor, with the 
additional one that it appears to include all or nearly 
all the additions to our knowledge of its subject that 
have been made since the appearance of the first edi- 
tion I'he American references are, for an English 
work, especially full and appreciative, and we can 
cordially recommend the volume to American read- 
ers. — Journ. of Nervous and Mental Disease, Oct. 
1878. 

This second edition of Dr. Barnes's great work 
comes to us containing many additions and improve- 
ments which bring it up to date in every feature. 
The excellences of the work are too well known to 
require enumerntion, and we hazard the prophecy 
that they will for many years maintain its high po- 
sition as a standard text-book and guide book for 
students and practitioners. — N. G. Med. Journ., 
Oct. 1878. 



Henry C. Lea's Publications — {Diseases of Women). 



23 



miMET (THOMAS ADDIS). M.D. 

-^ Surgeon to the Woman's Uos-pital, New York, etc. 

THE PRINCIPLES AND PRACTICE OF GYNECOLOGY, for the 

use of Students and Practitioners of Medicine. In one large and very handsome octavo 
volume of 856 pages, with 130 illustrations. Cloth, $5; leather, $6. {Just Ready) 
Dr Eniinet is so widely known as among the most eminent of those who have made gynas- 
cology a peculiarly American science th;it the profession cannot foil to welcome a work in which 
he has condensed the results i)f his long and extensive experience. He hns sought to consider 
the whole subject of the diseases peculinr to females in a manner which will adapt the volume, 
not only to the wants of the student as a text-book, but to those of the pmctitioner ns an aid in 
the emergencies of daily practice. A special feature of the work will be f aind in the numerous 
condensed tables, which convey at a glnnce, ami within the narrowest compass, the conclusions 
to be drawn from the many thousand cases which have passed under the care of the author. 
With trifling exceptions, the illustrations are all original, and the volume will be found in every 
point of typographical execution worthy of the distinguished position which is confidently anti- 
cipated for it. 

It may be said that he has had opportUDities for 
obsert-atioa and experience, for unfettered and an- 
restraiaed exper mentation, Hnd for testing the 
value of the original and dazzling operations first 
proposed and performed by his illastrious pred<^CcS- 
sors before referred lo, and for devising new opera- 
• tions and discovering pathological causes never 
before suspectf d or described, which no man in the 
profession has ever before secured. We also think 
that the readers of thit work will agree with us, 
after its careful perusal that he has a rare capacity 
for discriminating analyfi^, and geoerallyfor phi- 
losopbical deduction and the equally important 
quality of patient, honest, continued work. For the 
work a."? a whole, we have only praise. It deserves 
and will receivi^ the careful study of all who desire 
to keep on a level with the pr-gr^ss of Gynsecology. 
It embodies a larg.r amoant of carefally analyzed 
personal experience in a unique field for observa- 
tion than any volume on Diseases of Women which 
has yet been published. Its grtat merit consists in 
this— coming as it does from a thoroughly honest, 
competent, and able specialist, who became a spe- 
cialist only after an < xcelleut training and experi- 
ence as a general hospital phy.-ician and surgeon. 
The book is not one to be hastily glanced over, but 
w llsecure tbecritical stu'^y of Gynajcologists. Not 
only its style, which is individual and somewhat 
peculiar, but the new facts which it brings out, its 
original suggestions, its numerous and impn'tant 
ptatistical tables, and, in some instances, its unex- 
pected deductions, wUl compel attention, and will 
form the basis for a great deal of Gynecological 
study and literature iu the future. All who make 
themselves familiar with the contents of this vol- 
ume, will feel assured that T)r Emmet has well 
earned and wpW deserved the reputation which he 
has already won, a? one of the gre\t Gyncccologists 
of the present age. — Tke Am. Journ of Obstetrics, 
April, 1S79. 

We have examined this book with something more 
than ordinary care, and now lay it aside captivated 



by our impressions of it. From first to last, each 
page grows in interest, and one is struck with the 
practical tone of all that is said. It is indeed the 
gynaecological work for the practitioner. Its equal 
is not yet published, or at leas! we have not seen it. 
We cannot send 'his notice forward without reiter- 
ating that, in onr estimation, Emmet's Principles 
and Practice of Gynaecology is undoubteily the best 
book for the student, as well as the general practi- 
tioner, which is at present published. — Va. Med. 
Monthly, May, 1879. 

The advent of this important work has for some 
time been anxiously expected by all who are inter- 
ested in the subject of gynaecology, both here and 
abroad. The clinics held at the Woman's Hospital, 
and the minor writings referred to have acquired 
for Dr. Etnmet a reputation for skill as an operator, 
and experience in the special branch to which he 
has exclusively confined his attention, which is 
probably unrivalled by any one on this continent. 
The anticipations which have been awakened re- 
garding the character of this extended treatise, are 
not likely to be disappointed, if one may judge from 
the very cursory review we have made of its con- 
tents. — NtW Remedies, May, 1S79 

Few have had the rare opportunities of Dr. Em- 
met, and none have better improved that which was 
at their disposal. Sure are we that auy practi- 
tioner of medicine, specialist, or otherwise, who will 
read carefully this volume, will find that he pos- 
sesses a c'earer insight into a thousand problems 
that have hitherto perplexed him. It is one of the 
best original works on the diseases of women pub 
lished in this or any other land. We heartily com- 
mend it to the careful study of every medical man. 
—Detroit Lancet, May, 1S7"9. 

We are satisfied that whoever rearls the book care- 
fully will agree with ns that it is the best work on 
gynaecology that has ever been written. This is 
high prai>e, but we have no hesitation in giving it. 
— St. Louis Qlin. Record, May, 1879. 



riHADWlCK [JAMES R.), A.M., M.D. 
A MANUAL OF THE DISEASES PECULIAR TO WOMEN. 

neat volume, royal 12mo , with illustrations. {Preparing.) 



Iq one 



'DAMSBOTHAM [FRANCIS R.), M.D. • 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one l^irsre 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00 

''INCKEL [F.), 



W 



Professor and Director of the Gyncecological Clinic in the University of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent 
of the author, from the Second German Edition, by James Read Chabwick, M.D. In 
one octavo volume. Cloth, $4 00. (Lately Issued.) 



BANNER [THOMAS H.), M.D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustra- 
tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 



24 



Henry C. Lea's Publications— (il^f^■(Zw;^/er^). 



P 



LAYFAIR ( W. S.), M.D., F.R.C.F., 

Profefsor of Obstetric Medicine in King's GoJlege,ete. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Second American, from the Second and Revised English Edition. Edited, with Addi- 
tions, by Robert P. Harris, M.D. In one handsome oct-avo volume of 639 pages, with 
Cloth, $4.00; Leather, $5.00. (^Just Ready ) 



182 illustrations 

The position which this work has so qu'ckly taken 
in this country as an authoritative text-book renders 
any extended con>ideration of its jilan and scope 
unnecessary. Its merits, which are many, have al- 
ready found their way to the appreciation of students 
and practitioners alike in the length and breadth of 
the land. — Am. Supp. Ohdet. Journ. of Gt. Britain 
and Ireland, Oct. 1S7S. 

This excellent text-book has been submitted to a 
thorough and careful revision, and will be found 
fully up to the times in every department. The 
notes by the American editor enhance the value of 
the work for the American student. Those on the 
use of forcep.^ are particuUrly good, and constitute 
by themselves a valuable chapter. — N. Y. Med. 
Journ , Nov. 1878. 

The b^st work on the subject ever published in the 
English language It is written in a clear, pleasant 
style, without that verbosity which characterizes 
some modern and highly pretentious works. The au- 
thor is quite up with the times, both in practice and 



theory. It is the best text-book we have for students, 
and sufHciently full of ddtail to supply all the wants 
of the practitioner. We would gladly see it in the 
hands of all who practise midwifery. — CawordiaTi 
Journ. of Med. Sci., Nov. 1S7S. 

Probably this is the very best and most useful 
manual of midwifery now available to the profes- 
sion. It is written in lucid, scholarly Eaali^h, which 
some of our cis-Atlantic writers would do well to 
imitate. There has been no attempt to swell the 
magnitude of the work by fine writing, or by lengthy 
discussions ofobfcure points of which no trustworthy 
solution has yet been reached ; on the contrary, the 
tendency is throughout obviously towards simplic- 
ity. The chapter upon the Mechanism of Labor 
(which ought to be the crowning chapter in a trea- 
tise on ob.^itetrics) is remarkably clear and good, and 
is divested of those features which in almost every 
other work we know lets only darkness instead of- 
light in upon the subject. — N. 0. Med. Journ., Oct. 
1878. 



J?ARiVES [FANCOURT), M.D., 

-*-^ Physician to the General Lying-in Hospital, London. 

A MANUAL OF MIDWIFERY FOR MIDWIYES AND MEDICAL 

STUDENTS. With 50 illustrations. In one neat royal 12mo. volume of 200 pages; 
cloth, $1 25. i^Noiu Ready.) 
The publisher takes pleasure in presenting thii manufil of midwifery to students and the 
junior members of the profession, feeling assured that it will be found of great value, for 
though compressed in size, the language is concise and plain ; and while not entering upon 
the general discussion of obstetric operations, most distinct directions are given for the man- 
agement of childbed, its accidents and emergencies, and the previous and subsequent treat- 
ment of the patient. 



The book is written in plain, and as far as pos- 
sible in un'echnical language. Any tntelligent mid- 
wife or medical ."-tudent can eai-ily comprehend the 
directiaus It will undoubtedly fill a want, and 
will be popuiar. with taose for whom it has been 
prepared. The exam ning questions at the back 
will be found very ui^liA.— Cincinnati Med. News, 
Aug 1879. 



The style is clear, and the book will, doubtless, 
be useful to the persons for whom it is intended.— 
London Med. Times and Gazette, Aug. 30, 1879. 

The book is written with as little technical lan- 
guage as possible. Any intelligent midwile or med- 
ical student can easily understand the directions. 
It will undoubtedly be found very useful. — Ohio 
Med Recorder, Sept. 1879. 



rpHE OBSTETRICAL JO URNAL. [Free of postage for 1879.) 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 

Including Midwifery, and the Diseases op Women and Infants. With an American 
Supplement, edited by J. V. Ingham, M.D. A monthly of about 96 octavo pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 

Commencing with April, 1873, the ObstetricalJournal consists of Original Papersby Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and 
abroad; Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and 
Notes, Editorial, Historical, Forensic, and Miscellaneous; Selections from Journals; Cor- 
respondence, &c Collecting together the vast amount of material daily accumulating in this 
important and rapidly improving department of medical science, the value of the infor- 
mation which it presents to the subscriber may be estimated from the character of the gen- 
tlemen who have alreadj promised their support, including such names as those of Drs. At- 
THiLL, Aveling, Robert Barnes, J. Henri Bennet, Nathan Bozeman, Thomas Chambers, 
Fleetwood Churchill, Charles Clay, Johm Clay, Matthews Duncan, Artuur Farre, 
Robert Greenhalgh, Graily Hewitt, Braxton Hicks, Alfred Meadows, W. Leish- 
MAN, Alex. Simpson, Heywood Smith, Tyler Smith, Edward J. Tilt, Lawson Tait, 
Spencer Wells, <fcc. &c. ; in short, the representative men of British Obstetrics and Gynae- 
cology. 

In order to render the Obstetrical Journal fully adequate to the wants of the Ameri- 
can profession, each number contains a Supplement devoted to the advances made in Obstet- 
rics and Gynaecology on this side of the Atlantic. This portion of the Journal is under 
the editorial charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, 
books for re/iew, &c., may be addressed, to the care of the publisher. 

*^* Complete sets from the beginning can no longer be furnished, but subscriptions can 
commence with January, 1879, or Vol. VII., No 1, April, 1879. 



Henry C. Lea's P\jbi.jcatio^s— (Mi divifery, Surgery). 



25 



r EISHMAN ( WILLIAM), M.D., 

^ Regius Professor of Midwifery in the University of Glasgow. &c. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Third American edition, revited by 
the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia 
Hospital, &c. In one large and very handsome octavo volume, with about two hundred 
illaistrations. {Shortly.) 

Author's Preface. 
The publication of a third American edition of his work affords the author an opportunity, 
of which he gladly avails himself, of expressing the great gratification which he has experienced 
in the generous appreciation of his lab .rs by his colleagues in America. Of the many criticisms 
which have appeared, none have been more valuable or useful to him than those of the Ameri- 
can medical press. The methods of teaching on his side of the A lantic being somewhat d.ffer- 
ent it has been found necessary to make some modifications in order to make this and the 
previous edition quite intelligible. This has been ably done by Dr. John S. Parry ; and, without 
committirg himself to all that has been added, the author has much pleasure in acknowledging 
the courtesy and ability with which this task has been performed. In the preparation of the 
present edition, such alterations and modifications have been made as the progress of Obstetri- 
cal Science seems to require. The large circulation which the work has attained, has, indeed, 
imposed this duty upon the author as one to be conscientiously and carefully discharged, and 
in its performance he has been under many obligations to Dr. James Finlayson, which he has 
much pleasure in acknowledging. 



pARRY [JOHN S. 

Ohstftrician to the Philadelphia Hospital 



3LD., 

Vice-Prest. of the Ohstet. Society of Philadelphia. 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
Cloth, $2 50. {Lately Issued.) 

ffODGE [HUGH L.), M.D., 

Emeritus Professor of Midwifery, &c., in the University of Pennsylvania, &e. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures froia 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
The work of Dr. Hodge is something more than fact or principle Is left unstated or unexplained, 
a simple presentation of his particular views in the — Am. Med Times, ^ept. 8, 1S64 
dejartment of Obstetrics; it is something more It is very large, profusely and elegantly illustrat 
than an >rdinarytreatise on midwifery; it is in fact, ^^^ ^nd is fitted to take itts place near the works of 
a cyclopajdia of midwifery. He has aimed to em- ^^.^^^ obstetricians Of the American works on the 
body in a single volume the whole .science and art ot , rubied it is decidedly the best.— £c^m6. Med. Jour., 
Obstetrics. A.n elaborate text is combined with ac- y)qc. 1864 
curate and varied pictorial illustrations, so that no ' 

^=*^ Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 

OTliMSON {LEWIS A.), A.31, M.D., 

^ Surgeon to the Presbyterian Hospital. 

A MANUAL OF OPERATIVE SURGERY. In one very iiandsome 

royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 60. {Now Ready ) 

performing them. The work is handsomely illus- 
trated, aoil the def criptionsarecleHr and well drawn. 
It is a clever and useful volume; every student 
should possess one. The preparation of this work 
does away with the necessity of pondering over 
lai-.!?er works un surgery for de.scripiions of opera- 



The work before us is a well printed, profusely 
illQStrated manual of over four hundred and seventy 
pages. The novice, by a perusal of the work, will 
gain a good idea of the general domain of operative 
surgery, while the practical surgeon has presented 

to him within a very concise and intelligible form .„_. .. ,_ _-^_-^ ... ,. .^ 

the latest and most approved selection.s of operative j cious, as it presents in a nut-shell just what is wanted 
procedure. Theprec'.'^ion ard coociseness with which ; by the surgeon without an elaborate search to find 
the different operations are described enable the it. — Md. Med Journal, Aug. 1S78. 
author to compress an immense amount of practical j Ti^g author's conciseness and the repleteness of 
information iQ a very small compass -i\r. Y. Medical i ^he work with valuable illustrations entitle it to be 
Recm-d, Aug. 3, 18(8. classed with the text-books fur students of operative 

This volume is devoted entirely to operative sur- I surgery, and as one of reference to the pructitiouer. 
gery, and is intended to familiarize the student with ' — Cincinnati Lancet and Clinic, July 27, 1S7S. 
the details of operations and the different modes of | 



SKET'S OPERATIVE SURGERY. In 1 vol. 8vo. 
cl., of 650 pages ; with about lOOwood-cnts. $3 26. 

CDOPER'S LECTURES ON THE PRINCIPLES AND 

Practice OF SuKGESY. Inl vol. 8vo. cl'h, 750 p. $2. 

GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
GERY. Eighth edit'n, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, aboutlOOO pp. .leather raided bandF. $fi 50. 

THE PRINCIPLES AND PRACTICE OF SURGERY. 
By William Pirrie, F.R.S.E., Profes'rof Surgery 
in the University of Aberdeen. Edited by John 



Neill, M.D., Professor of Surgery in the Pen n a. 
MedicalCollege,Surg'n to the Pennsylvania Hos- 
pital, &c. In one very handsome octavo vol. of 
780 pages, with 316 illustrations, cloth, $3 75. 
MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- 
rican, from the Third Edinburgh Edition. In one 
large 8vo. vol. of 700 pages, with 340 illustrations, 
cloth, $3 75. 

MILLER'S PRACTICE OF SURGERY. Fourth Ame- 
rican, from the last Edinburgh Edition Revised by 
the American editor. In onelargeSvo. vol. of nearly 
700 pages, with 364 illustrations: cloth, $3 75 



26 



Henry C. Lea's Publications — {Surgery). 



(IROSS [SAMUEL D.), M.D., 

^^ Professor of Surgery in the Jefferson Medical College of Philadelphia. 

SYSTP]M OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pp., strongly bound in leiither, with raised bands, $16. {Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In 
th* present revision no pains have been spared by the author to bring it in every respect fully 
up t( the day. To effect this a large part of the work has been rewritten, and the whole en- 
arged bj uearly one fourth, notwithstanding which the price has been kept at its former very 
moderate rate. By the use of a close, though very legible type, an unusually large amount of 
matter is sondensed in its pages, the two volumes containing as much as four or five ordinary 
octavos This, combined with the most careful mechanical execution, and its very durable bind 
ing render!, it one of the cheapest works accessible to the profession. Every subject properly 
belonging to the lomain of surgery is treated in detail, so that the student who possesses this 
work may be said to have in it a surgical library. 



We have now brouglit uur task to acoTiflussion, and 
have seldom read a work wilh the [)ra(;tica] value ol 
which we liave been inoreinipresped. Every chapter is 
so conciiscly put together, that the busy practitioner, 
when in ditiiuulty, can at once find the information he 
requires, llis work, on the contrary, is cosmopolitan, 
the surgery of the world being fully represented in it. 
The work, in fact, is so historically unprejudiced, and 
so eminently practical, that it is almost a false compli- 
ment to say thatwe believe it to be destined to occupy 
a foremost place as a work of reference, while a system 
of surgery like the present system of surgery is the 
practice of surgeons. The printing and binding of the 
work is unexceptionable; indeed, it contrasts, in the 
latter respect, remarkably with Encrlish medical and 
surgical cloth-bound publications, which are generally 
80 wretchedly stitched as to require re- binding before 
they are any time iu [x&a.— Dul). Journ. of Med. Sci., 
March, 1874. 

Dr. Gross's Surgery, a great work, has become still 
greater, both in size and merit, in its most recent form. 
The difference in actual number of pages is not mftre 
than 130, but. the size of the page having been in- 
creased to what we believe is technically termed ••ele- 
phant," there has been room for considerable additions, 
which, together with the alterations, are improve- 
ments. — Lond. Lancet, Nov. 16, 1872. 

It combines, as perfectly as possible, the qualities of 
a text-book and work of reference. We think this last 



elition of Gross's "Surgery," will confirm his title of 
• Primus Lnte,r Pares." it is learned, scholar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write socompleteand faultless a 
treatise, or comprehend more solid, instructive matter 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers of mind, and the highest order of intellectual 
discipline and methodical disposition, and arrangement 
of acquired knowledge and personal experience. — N.Y. 
Med. Journ., Feb. 1873. 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Journ., Oct. 1872, 

The two magnificent volumes before us afford a very 
complete view of the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first edition of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of year.s of experience, labor.and study, all con- 
densed upon the great work before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase of these two volumes of immense research — 
Oincinnati Lancet and Observer, Sept. 1872. 

A complete system of surgery — not a mere text-book 
of operations, but ascientific accountuf surgical tlieory 
and practice in all its departments. — Brit, and For. 
Mori Chir. Rev., Jan. ISIS. 



f}Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 

and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
trations: nloth,$4 50. {Just Issued.) 
For reference and genera I information, the physician 
orsurceuncan find no work that meets their necessities 
more thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrations and good 
ideas, it has the unusual advantage of being easily 
comprehended, by the reasonable and practical manner 
in which the various subjects are systematized and 
arranged We heartily recommend it to the profession 
as a valuable addition to the important literature of di.«- 



eases of the urinary organs. — Atlanta Med. Journ., Oct 
1876. 

It is with pleasure we now again take up this old 
work in a decidedly new dress. Indeed, it must be re- 
garded as a new book in very many of its parts. The 
chapters on '' Diseases of the Bladder," " Prostate 
Body," and "Lithotomy," are splendid specimens of 
descriptive writing; while the chapter on '-Stricture" 
is one of the most concise and clear that we have ever 
read. — New York Med. Jou7-n.,N oy .1816. 



JJY the SA31E AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 



D 



RUITT [ROBERT], M.R.C.S., &^c. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octa-y o 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $6 0*1. 



All that the surgical student or practitiouerconld 
(jesire. — Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure. — 
Boston Med. and Surg. Journal. 

In Mr. Druitt'sbook, though containingonly some 
even hundred pages, both the principles and the 



aractice of surgery are treated, and so clearly and 
jerspicuously, as to elucidateevery important topii . 
We aave examined thebook most thoroughly, and 
can iay that this success is well merited. His- hoc k 
moreover, possesses the inestimable advantages of 
baving the subjects perfectly well arranged and 
clafsified and of being written in a style at once 
clear ind succinct. — Am. Journal of Med. Sciences. 



Henry C. Lea's Publications — {Surgery). 



21 



A SEHURST [JOHN, Jr. 

•^^ Prof, of Clinical Surgery, V 



M.D., 

Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia 

THE PRINCIPLES AND PRACTICE OF SURGERY. Second 

edition, enlarged and revised. In one very large and handsome octavo volume of over 
1000 pages, with 542 illustrations. Cloth, $6 ; leather, $7. {Just Ready.) 
Conscientiousness and thoroughness are two very i Ashbuvst's Surgery is too well known in this 
marked trails of character in the author of this ; country to require special commendation from us. 
book. Ont of these traits largely has grown the ; This, its second edition, enlarged and thoroiT^hly 
snccess of his mental fruit in the past, and the pre- ; revised, brings it nearer our idea of a model t°ext- 
sent otfer seems in no wise an exception to what has book than any recently published treatise. Thouo-h 
gone before. The general anangement of the vol- ' numerous additions have been made, the size of t?ie 
time is the same as in the first edition, but every part 
has been carefully revi;ed, and much new matter 
added.— P/iiZa. 3Ied. Times, Feb. 1, 1S79. 



We have previously spoken of Dr. Ashhurst's 
work in terms of praise. We wish to reiterate those I { 
terms here, and to add that no more satisfactory 
representation of modern surgery has yet fallen 
from the press. In point of judicial fairness, of 
power of condensation, of accuracy and conciseness 
of expresfion and thoroughly good English, Prof. 
Ashhurst has no superior among the surgical writers 
in America. — Am. Practitioner, Jan. 1S79. 



work is not materially increased The main trouble 
of text books of modern times is that they are too 
cumbersome. The student needs a book which will 
furnish him the most information in the shortest 
time. In every respect this work of Ashhurst is 
model text-book- full, comprehensive and com- 
pact.— iVa.s•/^^■^Z?e Jour, of Med. and Surg., Jan. '79 



The attempt to embrace in a volume of 1000 pages 
the whole field of surgery, general and special, 
would be a hopeless ta.-k unless through the most 
tirele.^s industry in collating and arranging, and 
the wisest judgment in condensing and excluding. 
These facilities have been abundantly employed by 
the author, and he has given us a most excellent 
treatise, brought up by the revision for the second 
edition to the latest d^te. Of course this book is not 
designed for specialists, but as a course of general 
surgical knowledge and for general practitioners, 
and as a text-book for students it is not surpa>sed 
by any that has yet appeared, whether of home or 
foreign authorship. — N. Carolina Med. Journal, 
Jan. 1879. 



The favorable reception of the first edition is a 
guarantee of the popularity of this edition, which is 
fresh from the editor's Lands with many enlgrge- 
ments and improvements. The author of this work 
is de.servedly popular as an editor and writer, and 
his contributions to the literature of surgery have 
gained for him wide reputation. The voTum'e now 
offered the profession will add new laurels to those 
already won by previous contributions. We can 
only add that the work is well arranged, filled with 
practical matter, and contains in brief and clear 
languaiie all that is necessary to be learned by the 
student of surgery whilst in attendance upon lec- 
tures, or the general practitioner in his daily routine 
practice.— Jlf'/. Med. Journal, Jan. 1S79. 

The fact that this work has reached a second edi- 
tion so very soon after the publication of the first 
one, speaks more highly of its merits than anything 
we might say in the way of commendation. It 
seems to iiave immediately gained the favor of stu- 
dents and physicians.— C'iJtciTi. 3Ied. News, Jan. '79. 



B 



RYANT [THOMAS], F.R.C.S., 

Surgeon to Guy's Hospital. 

THE PRACTICE OF SURGERY. Second American, from the Sec- 

ond and Revised English Edition. With Six Hundred and Seventy. two Engravings on 
Wood. In one large and very handsome imperial octavo volume of over 1000 laro-e and 
closely printed pages. Cloth, $6 ; leather, $7. (Just Ready.) 
This work has enjoyed the advantage of two thorough revisions at the hand of the author since 
the appearance of the first American edition, resulting in a very notable enlargement of size and 
improvement of matter. In England this has led to the division of the work into two volunies 
which ure here comprised in one, the size being increased to a large imperial octavo, printed on 
a condensed but clear type. The series of illustrations has undergone a like revision, and will 
be found correspondingly improved. 

The marked success of the work on both sides of the Atlantic shows that the author has suc- 
ceeded in the eflFort to give to student and practitioner a souud and trustworthy guide in "the 
practice of Surgery; while the simultaneous appearance of the present edition in Eno-jand and 
in this country affords to the American reader the benefit of the most recent advances made 
abroad in surgical science. 

Another edition of this manual having been called 
for, the author has a vailed himself of the opportunity 



There are so many text-books of surgery, so many 
written by skilled and distnguished hands, that to ob 



tain the honor of a third edition in England is no light I to make no few alterations in the substance as wei" 
praise. Mr. Bryant merits tbi.*, by clearness of style, as in the airangemeut of the work, and, with a view 



and good judgment in selecting the operations he re- 
commends, in his new editions he goes carefully over 
the (Id grounds, in light of later research. On'these 
and many allied points, M^ Bryant is a calm and un- 
partisan observer, and his book throughout has the 
great merit cf m;dntaining the true scientific, judicial 
tone of mind.— i/e(/. and Surg. Ee.iorter, March 22, 
1S79. 



to Its improveiuent, has recast the materials and re- 
vised the whole. We ourselves are of the opinion 
that there is no better work on surgery extant — 
Cincinnati Med. Xtws, Maich, 1S79 



Bryant's Surgery has been favorablyreceived from 
the first, and evidently grows in the esteem ot the 
protession w.th each succeeding edition. In glanc- 

, . , . .1 . . . I iDg over the volume before us wefind proof in almon 

The work before us is the American reprint of the I every chapter of the thorough revision which me 
last London edition, and has the advantage over the | worn has undergone, many parts having been cnt 



-.v. r. 



latter in being of more convenient size, and in bein 
compressed into one volume. The author has rewrif- 
ten the greater part of the work, and has succeeded, 
in the amount ot new matter added, in making it mark- 
edly distinctive from previous editions. A few extra 
pages have been added, and also a few new illustrations 
introduced. The publishers have presented the work 
in a creditable style. As a concise and practical manual 

of British surgery it is perhaps without an equal, and i R,.^.^„. ^„H i.^r •,, ..^^...^ ^. 

will doubtless always be a favorite text-book with the I ?^ ,u ^ Ashnuist we will not attempt, but pre- 
student and practitioner. -iV. 1\ Med. Record, March n^fn^ntL!:^^*-^ r',''^ the high excellence of both, 
22, 1879. • ; pd-ny otheis will likewue be lorced to hesiiate lon^ 

in mdking choice between them -Cincinnati LarC- 
I cet and Oliiiic, March 22, 1&79. 



out and replaced by matter entirely fresh. 
Med. .lourn., April, 1S79. 

Welcome as the new edition is, and as much as it 
is entitled to commendation, yet its appearance at 
this time IS, in a cer.ain sense, a matter of regret as 
it will be ill competition with another work lately 
issued from the s^ime press. But, the ditiicu'lt ta^k 
of forming a judgment as to the relative merits of 



Henry C. Lea's Publications — (Surgery). 



^RIGHSEN {JO EN E. ), 

Professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- 
gravings on wood. It two large and beautiful octavo volumes of nearly 2000 pages : 
cloth, $8 50 ; leather, $10 50. (Now Ready.) 

In revising this standard work the authorhas spared no painsto render it worthy of acontinu- 
ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
level with the advance in the science and art of surgery made since the appearance of the 
last edition. To accomplish this has required the addition of about two hundred pages of text, 
while the illustrations have undergone a marked improvement. A hundred and fifty additional 
wood-cuts have been inserted, while about fifty other new ones have been substituted for figures 
which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
sented with the confident anticipation that it will maintain its position in the front rank of 
text-books for the student, and of works of reference for the practitioner, while its exceedingly 
moderate price places it within the reach of all. 



The sevealh edition is before the world as the last 
word of surgical scieace. There may be monographs 
which excel it upon certain points, but as a con- 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners, to 
read it, for it has been a peculiar province of Mr. 
Erichsen to demonstrate the absolute interdepend- 
ence of medical and surgical science We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an invaluable guide at the bedside. — Am Practi- 
tioner, April, 1878. 

It is no idle compliment to say that this is the t)est 
edition Mr. Erichsen has ever produced of his well- 
known book. Besides inheriting the virtues of is 
predecessors, it possesses excellences quite its own. 
Having stated that Mr. Erichsen h^s incorporated 
into this edition every recent improvement in the 
science and art of surgeiy, it would be a supereroga- 
tion to give a detailed criticism, lu short, we un- 
hesitatingly aver that we know of no other single 
work where the student and practitioner can gain at 
oncesoclear aninsight into the principles of surgery, 
aud so complete a knowledge of the exigencies of 
surgical practice.— iowd'jTi Lancet, 'E eh. li:, 1878 

For the past twenty years Erichsen's Surgery has 
maintained its place as the leading text- book, not only 
in this country, but in Great Britain. That it is able 
to hold its ground, is abundantly proven by the tho- 
roughness with which the preset t edition has bejn 
revised, and by the large amount of valuable mate- 
rial thai has been added. Aside from this, ( ne hun- 
dred and fifty new illustrations have been inserted, 
including quite a number of microscopical appear- 
ances of path'il jgical processes. So marked is this 
change for the better, that the work almost appears 
as an entirely new one — Med. Reiord, Feb. 23,1878 



Of the many treatises on Sur^jery which it has been 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as thp classic 
treati.'^e of Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, his unsurpassed grasp 
of his subject, and vast clinical experience, qualify him 
admirably to write a model text-book. When we wish', 
at the least cost of time, to learn the most of a topic in 
surgery, we turn, by preference, to his work. It is a 
plea,sure, therefore, to see ttiat the appreciation of it is 
general, and has led to the appearance of anoiher edi- 
tion. — Med. and Surg. Eeporur, Feb. 2, 1S78. 

Notwithstanding the increase in size, we observe that 
much old matter has been omitted. The entire work 
has been thoroughly written up, and not merely amend- 
ed by a few extra chapters A great improvement has 
been made in the illustrations. One hundred and fifty 
new ones have been added, and many of the old ones 
have been redrawn The author highly appreciates the 
favor wiih which his work has been received by Amer- 
nan surgeons, aud has endeavored to render his latesc 
edition more than ever worthy of their approval. Thit 
he has succeeded admirably, must, we chink, be the 
general opinion. We heartily recommend the book to 
both student and practitioner. — N. Y.Med, Journal, 
Feb. 1878. 

Erichsen has stood so prominently forward for 
years as a writer on Surgery, that his reputation is 
world wide, and his name is as familiar to the med- 
ical student as to the accomplished and experienced 
surgeon The work is not a reprint of formtr edi- 
tions, but has in many places been entirely rewrit- 
ten. Eecent improvements in sui'gery have not es- 
caped his notice, various new operations have been 
thoroughly analyzed, and their merits thoroughly 
discussed One hundred and fifty new wood-cuts 
add to the value of this work.— iV. 0. Med. and Surg. 
Journal, March, 1878. 



H 



OLMES {TIMOTHY), M.D., 

Surgeon to St George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather, $7. 
(Jiist Issued.) 

its force and distinctness. —iV^.r. Med. Record, April 
14, 1876. 

It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the 
time togiveattentionto more minute and extended 
works and to the medical student. In fact, we know 
of no one we can more cordially recommend. The 
author has succeeded well in giving a plain and 
practical account of each surgical injury aud dis- 
ease, and of the treatment which is most com- 
monly advisable. It will no doubt become a popu- 
lar workin the profession, and especially as a test- 
book.— CiTicinwaiz Med. News, April, 1S76. 



This is a work which has been looked for on both 
sides ofthe Atlantic with much interest. Mr. Holmes 
is a surgeon of large and varied experience, and one 
of the best known, and perhaps the most biilliant 
writer upon surgical subjects in England. It is a 
book for students — and an admirable one — and for 
the busy general practitioner. It will give a student 
all the knowledge needed to pass a rigid examina- 
tion. The book fairly j u.~.tifie6 the high expectations 
that were formed of it. Its style is clear aud forcible, 
even brilliant at times, and the conciseness needed 
to bring it within its proper limits has not impaired 



ASHTON ON THE DISEASES, INJURIES, and MAL- 
FORMATIONS OF THE RECTUM AND ANUS: 
with remarks on Habitual Constipation. Second 
American, from the fourth and enlarged London 
Edition. With illustrations. la one 8vo vol. of 
287 pages, cloth, |3 25. 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, with 
an additional chapter on Military Surgery. One 
1 2m 0. vol. of 3S3pag3s with 181 wood-cuts. Cloth, 

$175. 



Henry C. Lea's Publications — {Ophthalmology). 29 

LJAMILTON [FRANK H.), M.D., 

*-J- Professor of Fractures and Dislocations, Ac, in Belleime Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Fifth edition, revised and improved. In onelargeand handsome octavo volume 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 : leather, $6 75. {Lately Issned.) 

This work is well known, abroad as well as at home, as the highest authority on its important 
subject — an authority recognized in the courts as well as in the schools and in practice — and 
again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
author has thus had the opportunity of making have enabled him to give the most careful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
to perfect the work by the aid of his own enlarged experience, and to incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition. It will there- 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographical execution, and the volume is presented to the profession in the confident 
hope that it will more than maintain its very distinguished reputation. 

There is no better work on the subject in existence 
than that of Dr. Hamilton. It should be in the posses- 
sion of every greneraJ practitioner and surgeon.— T/?e 
Am. Jnurn. of Obstetrics. Feb. 1876. 

The value of a work like this to the practical physi- 
3taa and surgeon can hardly be over-estimated, and the 
necessity of haviny; such a book revised to the late-^t 
dates, not merely on account of the practical importance 



of its teachings, but also by rea.«on of the medico-legal 
bearings of the cases of which it treats, and which have 
recently been the subject of useful papers by Dr Hamil- 
ton and others, is sufficiently obvious to every one. The 
present volume seems to amply fill all the requisites. 
We can safely recommend it as the best of its kind in 
the English language, and not excelled in any other. 
Journ. of Nervous and Mental Disease, Jan.i876. 



B 



O 



ROWNE [EDGAR A.), 

Surgeon to the Liverpool Eye and Ear Infirmary, and to the Dispensary for Skin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structions in Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- 
tions. In one small volume royal l2mo. of 120 pages : cloth, $1. {JVow Ready.) 

ARTER [R. BRUDENELL), F.R.C.S., 

Ophthalmic Surgeon to St. George s Ho.spital, etc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 

ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 

handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $S 75. {Just 

Issued. ) 

It would be difficult for Mr. Carter to write an unin- . manner, easy of comprehension, and hence the more 

structive book, and impossible for him to write an un- } valuable. We would especially commend, however, as 

interestingone. Even on subjects with which he is not ' worthy of high praise, the manner in which the thera- 

bound to be familiar, hecan discourse with a rare degree \ peutics of disease of the e^eis elaborated, for here tlie 

of clearness and effect. Our readers will therefore not j author is particularly clear and practical, where other 

be surprised tc learn that a work by him on the Diseases I writers are unfortunately too often deficient. The final 

ol the Kye makes a very valuable addition to ophthat- I chapter is devoted to a discus>ion ot the use.':andseler- 

mic literature. , . . The book will remain one useful [ tion ofspectacies, and is admirably compact, plain, and 



alike to the general and thespecial practitioner. — Lo7i- 
don Lancet, Oct. 30,18" " 



It is with great pleasure that we can endorse the work 
s a most valuable contribution to practical ophthal- 
lology. Mr. Carter never deviates from the end he has 
in view, and presents the subject in a clear and coucist j Oct^^3 IS" 



useful, especially the paragraphs on the treatment of 
presbyopia and myopia. In conclusion, our thanks are 
due the author for many useful hints in the great sub- 
ject of ophthalmic surgery and therapeutics, afield 



a most viiluable contribution to practical ophth.il- , .^.^ere of late years we glean but a few grains of sound 
mology . Mr Carter never deviates trom the end he has I ^^y^^^t from a mass of chaff —New York Medical Record, 



-^ELLS [J. SOELBERG), 

Professor of Ophthalmology in King'' 8 College Hospital, Ac. 

A TREATISE ON DISEASES OF THE EYE. Third American, 

from the Fourth and Revised London Edition, with additions ; illustrated with numerous 
engravings on wood, and six colored plates. Together with selections from the Test-types 
of Jaeger and Snellen. In one large and very handsome octavo volume. {Preparing.) 

ETTLESHIP [EDWARD), F.R.C^, 

Ophthalmic Surg, and Led. on Ophth. Surg at St. Thomas' Hospital, Lcrdon. 

MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo. 

volume of about 350 pages. {Shortly.) 



N' 



' AVRENGE [JOHNZ.], F.R.C.S., 

Editor of the Ophthalmic Review, &c. 

A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In 
one very handsome octavo volume, cloth, $2 75. 



-^A WSON [GEORGE), F.R.C.S. Engl., 

Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields , &c . 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

diate and Remote Effects. With about one hundred illustrations. In tne very hand- 
some octavo volume, cloth, $3 50. 



30 



Henry C. Lea's Publications^ — {Medical Jurisprudence). 



jyURNETT [CHARLES H.), M.A , M.D., 

•^ Aural Surg, to the Presb. Hasp., Surgeon-in-tharge ofthelnfir.forDis. of the Ear, Phila. 

THE EAR, ITS ANATOMY. PHYSIOLOGY, AND PISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, 
$5 50. {Just Ready.) 
Recent progress in the investigation of the structures of the ear, and advances made in the 
modes of treating its diseases, wouldseem to render desirable a new work in which all the re- 
sources of the most advanced science should be placed at the disposal of the practitioner. This 
it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in 
the special study of the subject are a guarantee that the result of his labors will prove of service 
to the profession at large, as well as to the specialist in this department. 

Foremost among the numerous recent contrihu | medical student, and its study will well repay the 



tions to aural literature will be ranked this work 
of Dr. Burnett. It is impossible to do justice to 
this volume of over 600 pages in a necessarily brief 
notice. It must suffice to add (hat the book is pro- 
fusely and accurately illustrated, the references are 
conscientiously acknowledged, while the result has 
been to produce a treatise which will henceforth 
rank with the classic writings of "Wilde and Von 
Trolsch. — r/je Lond. Praditioner, May, 1879. 

On account of the great advances which have been 
made of late years in otology, and of the increased 
interest manifested in it, the medical profession will 
welcome this new work, which presents clearly and 
concisely its present aspect, whilst clearly indi- 
cating the direction in which further researches can 
be most profitably carried on. Dr. Burnett from his 
own matured experience, and availing himself of 
the observations and discoveries of others, has pro- 
duced a work, which as a text-book, stands /aci7e 
princeps in our language. We had marked several 
passages as well worthy of quotation and the atten- 
tion of the general practitioner, hut their number and 
the space at our command foibid. Perhaps it is bet- 
ter, as the book ought to be in the hands of every 



busy practitioner in the pleasure he will derive from 
the agreeable sfyle in which many otherwise dry 
and mostly unknown subjects are treated. To the 
specialist the work is of the highest value, and bis 
sense of gratitude to Dr. Burnett will, we hope, be 
proportionate to the amount of benefit he can obtain 
from the careful study of the book, and a constant 
reference to its trustworthy pages. — Edinbui gh 
Med. Jour., Aug. 1878. 

The book is designed especially for the use of stu- 
dents and general practitioners, and places at their 
disposal much valuable material. Such a book as 
the present one, we think, has long been needed, and 
we may congratulate the author on his success in 
filling the gap. Both student and practitioner can 
study the work with a great deal of benefit. It is 
profusely and beautifully illustrated. — N. Y. Hos- 
pital Gazette, Oct. 15, 1877. 

Dr. Burnett is to be commended for having written 
the best book on the subject in the English language, 
and especially for the care and attention he has 
given to the scientific side of the subject. — N. J. 
Med. Journ., Dec. 1S77. 



^AFLOR [ALFRED S.),M.D., 

Lecturer on Med. Jurisp. and Chemistry in Ouy's Hospital. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE, Third American, from the Third and Revised English Edition. In one 
large octavo volume of 860 pages ; cloth, $5 50 ; leather, $6 60. {Just Issued.) 



The present is based upon the two previous edi- 
tions; "but the complete revision rendered necessary 
by time has converted it into a new work." This 
statement from the preface contains all that it is de- 
sired to know in reference to the new edition. The 
works of this author are already in the library of 
every physician who is liable to be called upon for 
medico-legal testimony (and what one is not?), so that 
all that is required to be known about the present 
book is that the author has kept it abreast with the 
times. What makes it now, as always, especially 
valuable to the practitioner is its conciseness and 
practical character, only those poisonous substances 



being described which give rise to legal Investiga- 
tions.— T^e Clinic, Nov. 6, 1S7.5. 

Dr. Taylor has brought to bear on the compilation 
of this volume, stores of learning, experience, and 
practical acquaintance with his subject, probably far 
beyond what any other living authority on toxicol- 
ogy could have amassed or utilized. He has fully 
sustained his reputation by the consummate skill 
and legal acumen he has displayed in the arrange- 
ment of tne subject-matter, and the result is a work 
on Poisons which will be indispensable to every stu- 
dent or practitioner in law and medicine. — The Dub- 
lin Journ. of Med. Sci., Oct. 1875. 



B 



Y THE SAME AUTHOR. 

xVIEDICAL JURISPRUDENCE. Seventh American Edition. Edited 

by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00, {Lately Issuofl.) 



To the members of the legal and medical profes- 
sion, it is unnecessary to say anything commenda- 
tory of Taylor's Medical Jurisprudence. We might 
as well undertake to speak of the merit of Chitty's 
Pleadings.— O/i'corp'O Legal News, Oct. 16, 1873. 

It is beyond question the most attractive as well 
as most reliable manual of medical jurisprudence 
published in the English language. — Am. Journal 
nf Syphilography, Oct. 1873. 

It is altogether superfluous for us too flfer any thing 
inbehalf of a work on medicaljurisprudence by an 
author who isalmost universally esteemed tobe the 



best authority on this specialty in our language. On 
this point, however, we will say that we consider Dr. 
Taylor to be the safet^t medico-legal authority to fol- 
low, ingeneral, with which we areacqnaintedin any 
language.— Ta Clin. Record, Nov. 1873. 

Thislastedition of the Manual ieprobably thebest 
of all, as it contains more material and is u orked up 
to the latest views of the author as expressed in the 
last edition of the Principles. Dr. Reese, the editor 
of the Manual, has done everything to make his 
workacceptable to his medical countrymen. — N. Y 
Med. Record, Jan. 15, 1874. 



or THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00 ; leather, $12 00 
ThiJ great work is now recognized in England as the fullest and most authoritative treatise on 
every department of its important subject. In laying it, in its improved form, before the Amer- 
ican profession, the publisher trusts that it will assume the same position in this country. 



Henry C. Lea's Publications — (Miscellaneous). 



31 



fTHOMPSON {SIR HENRY), 

J- Surgeon and Prn/es.^or of Clinica I Surgery to University College Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. {Jzist Issued.) 
T>T THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
{Late/y Published.) 

JDOBERTS {WILLIAM), M.D., 

-Lt Lecturer on Medicine in the Manchester School of Medicine, etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

BASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. {Lately 
Published.) 

rrUKE {DANIEL HACK), M.D., 

J- Joint author of " The Manual of Psychological Medicine,^ ^ &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. {Lately Issued.) 

jyLANDFORD {G. FIELDING), M.D., F.R.G.P., 

-*-' Lecturer on Psychological Medicine at the School of St. George' s Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 
It satisfies a want which must have been sorely i actually seen in practice and the appropriate treat- 



feltby the busygeneralpractitioners of thiscountry. 
.i takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sinity. We call particular attention to this feature 
of the book, as givingit a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 



ment for them, we find in Dr. Blacdford's work a 
considerable advance over previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
Mdinary manuals in the English language or (so far 
as our own reading exiends)in any other. — London 
Practitioner, Feb. 1871. 



EA {HENRY C). 

^SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised 
and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
$2 50. {Just Ready.) 



The appearance of a new edition of Mr. Henry C. 
Lea's " iSuperstition and Force" is a sign that our 
highest scholar; hip is not without honor in its na- 
ti^e country. Mr. Lea has met every fresh demand 
for his work with a careful revision of it, and the 
present edition is not only fuller and, if possible, 
more accurate than either of the preceding, but, 
from the thorough elaboration, is more like a har- 
monious concert and less like a batch of studies. — 
The Nation, Aug. 1, 1S7S. 

Many will be tempted to say that this, like the 
*^DeclineaudFall,"isoQe of the uacriticizable books 
Its facts ate innumerable, its deductions simple and 
inevitable, and its chtvau^-dt-frise of references 
bristling and dense enough to make the keenest, 
stoutest, and best equipped assailant think twice 
before advancing. Nor is there anything contro- 
versial in it to provoke assault. The author is no 



polemic. Though he obviously feels and thinks 
strongly, he succeeds in attaining impartiality. 
Whetter looked on as a picture or a mirror, a work 
such as this has a lasting Y&lixG.—LippincotVs 
Magazine, Oct. 1S7S. 

Mr. Lea's curious historical monographs, of which 
one cf the most important is here reproduced in an 
enlarged form, have given him an unique position 
among English and American scholars. He is dis- 
tinguished for his recondite and affluent learning, 
his power of exhaustive historical analysis, the 
breadth and accuracy of his researches among the 
rarer sources of knowledge, the gravity and temper- 
ance of his statements, combined with singular 
earnestness of conviction, and his warm attachment 
to the cause of human freedom and intellectual pro- 
gress.— iV^. Y. Tribune, Aug. 9, 1878. 



£ 



Y THE SAME AUTHOR. {Late'y Published.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large 
royal 12mo. volume of 516 pp.; cloth, $2 75. 

The story was never told more calmly or with , has a peeuliarimportancefortheEnglish student, and 
grsater learning or wiser thought. We doubt, indeed, ' is a chapter on Ancient Law likely to be regarded as 
if any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner , Dec. 1870. 



Mr. Lea's latest work, " Studies in Church History." 
fully sustains the promise of the first. It deals with 
three subjects — the Temporal Power, Benefit of 
Clergy, and Excommunication, the record of which 



final. We can hardly pas.-, from our mention of such 
works as these — with which that on "Sacerdotal 
Celib'^cv" should be 'nolufled — without noting the 
literary phenomenon that the head of one of the first 
American houses isalso the writer of some of its ffost 
original books. — London Athenceurn, Jan. 7 1871. 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE 



American Journal of the Medical Sciences 
Abstract, Monthly, of the Med. Sciences 

Allen's Anatomy 

Anatomical Atlas, by Smith and Horner 
Ashton on the Rectum and Anus 
Attfieid's Chemistry .... 
Ashwellon Diseases of Females 
Ashhurst's Surgery . . . 
Browne on Ophthalmoscope . 
Browne on the Throat .... 
Burnett on the Ear .... 
Barnes on Diseases of Women 
Barnes' Midwifery .... 

Bellamy's Surgical Anatomy 
Bryant s Practical Surgery 
Bloxam's Chemistry .... 
Blandford on Insanity .... 
Basham on Renal Diseases . 
Brinton on the Stomach 
Barlow's Practice ot Medicine . 
Bowman's (John E.) Practical Chemistry 
Bowman's (John E.) Medical Chemistry 
Bristowe's Practice .... 
Bumstead on Venereal 
Bumstead and CuUerier's Atlasof Venereal 
carpenter's Human Physiology 
(Urpenter on the Use and Abuse of Alcohol 
Cornil and Rauvier .... 



Carter on the Eye . 
Cleland's Dissector 
Classen's Chemistry 
Clowes' Chemistry 
Century of American Medicine 
Chadwick on Diseases of Women . . -23 

Charcot on the Nerv^ous System . . . .18 
Chambers on Diet and Regimen . . , -18 
Christison and Griffith's Dispensatory . . 14 
CtLurchiU's System of Midwifery . • . 21 
Churchill on Puerperal Fever . . . .21 
Condie on Diseases of Children . . . .20 
Cooper's (B. B.) Lectures on Surgery , 2o 

Gallerier's Atlas of Venereal Diseases . . 19 
Cyclopaedia of Practical Medicine . . .14 
Dalton's Human Physiology . . . . p 

Davis's Clinical Lectures I4. 

Oewees on Diseases of Females . . . .21 
Druitt's ModernSurgery 
Dunglison's Medical Dictionary ... 4 

Ellis's Demonstrations in Anatomy . . .7 
Erlchsen's System of Surgery . . .28 

Emmet on Diseases of Women . . .23 

Farquharsou's Therapeutics • ... 12 

Fenwick's Diagnosis 34 

Fialayson's Clinical Diagnosis . . . .18 
Flint on Respiratory Organs . . . . I9 

Flint on the Heart I9 

Flint's Practice of Medicine 15 

Flint's Essays I5 

Flint's Clinical Medicine I5 

Flint on Phthisis I9 

Flint on Percussion I9 

Fothergill's Handbook ofTreatment . . , ig 
Fothergill's Antagonism of Therapeutic Agents . 16 
Fownes's Elementary Chemistry . . . lo 
Fox on Diseases of the Skin . . . .17 

Fuller on the Lungs, &c ... I9 

Green's Pathology and Morbid Anatomy . . I4 

Glibson's Surgery .2") 

Gluge's Pathological Histology, by Leidy . I4 

Gray's Anatomy . « 

Galloway's Analysis 9 



PAGE 

. 1 
. 3 

7 

. 7 



Griffith's (R. E.) Universal Formulary 
Gross on Urinary Organs .... 
Gross on Foreign Bodies in Air-Passages . 
Gross's Principles and Practice of Surgery 
Habershon on the Abdomen .... 
Hamilton on Dislocations and Fractures 
Hartshorne's Essentials of Medicine . 
Hartsnorne's Conspectus of the Medical Sciences 5 



Hodge's Obstetrics 

Holland's Medical Notes and Reflectiont . 
Holmes's Surgery . . . . . 

Holden's Landmarks .... 

Horner's Anatomy and Histology 

Hudson on Fever 

Hill on Venerea] Diseases 

Hillier's Handbook of Skin Diseases 

Tones (C. Handlield) on Nervous Disorders 

Kirkes' Physiology 

jKnapp's Chemical Technology . 
Lea's Superstition and Force 
Lea's Studies in Church History 

Lee on Syphilis 

Lincoln on Electro- Therapeutics 
Leishman's Midwifery 



PAGB 

. 25 

. 14 

. 28 

. « 

. 7 

. 19 

. 20 

. 17 

. 18 

. 8 

. 11 

. 31 

. 31 

. 20 

. 18 

. 2o 



La Roche on Yellow Fever 14 



Hartshorne's Anatomy and Physiology 
Hamilton on Nervous Diseases 
Heath's Practical Anatomy 
Hoblyn's Medical Dictionary 
Hodge on Women 



La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye 

Lehmann's Physiological Chemistry, 2 vols 

Lehmann's Chemical Physiology 

Ludlow's Manual of Examinations . 

Lyons on Fever 

Medical News and Library . 

Meigs on Puerperal Fever . 

Miller's Practice of Surgery 

Miller's Principles of Surgery . 

Montgomery on Pregnancy 

Nettleship's Ophthalmic Medicine 

Neil! and Smith's Compendium of Med . Science 

Obstetrical Journal 

Parry on Extra-Uterine Pregnancy 

Pavy on Digestion .... 

Pavy on Food ..... 

Parrish's Practical Pharmacy . 

Pirrie's System of Surgery . 

Playfair's Midwifery .... 

Quain and Sharpeys Anatomy, by Leidy 

Reynolds' Practice of ftiedicine . 

Roberts on Urinary Diseases 

Ramsbotham on Parturition 

Remsen's Principles of Chemistry 

Rigby's Midwifery .... 

Rodwell's Dictionary of Science . 

Siimson's Operative Surgery 

Swayne's Obstetric Aphorisms . 

Seller on the Throat .... 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery . 

Slade on Diphtheria .... 

Schafer's Histology .... 
Smith (J L.) on Children . 
Smith (H. H.) and Horner's Anatomical Atlas 
Smith (Edward) on Consumption 
Smith on Wasting Diseases in Children 
Stilld's Therapeutics .... 
Stille & Maisch's Dispensatory . 
Sturges on Cl'inical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicine 

Tanner on Pregnancy .... 

Taylor's Medical Jurisprudence . 

Taylor's Principles and Practice of Med Jnrisp 

Taylor on Poisons 

Tuke on the Influence of the Mind . 

Thomas on Diseases of Females . 

Thompson on Urinary Organs 

Thompson on Stricture .... 

Todd on Acute Diseases 

Woodbury's Practice .... 

Walshe on the Heart ... 

Watson's Practice of Physic 

Wells on the Eye 

West on Diseases of Females 

West on Diseases of Children 

West on Nervous Disorders of Children 

What to Observe in Medical Cases 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson's Handbook of Cutaneous Medicine 

Wifliler's Organic Chemistry .... 9 

Winckel on Childbed 23 



19 
2 
22 
2.'> 
25 
21 
29 
.^ 
24 

2.T 

IS 
18 
11 
2o 
24 
7 

17 

?l 

23 
9 

21 
5 

25 

21 

19 

28 
7 

25 

19 
7 

21 
7 

19 

20 

12 

13 

14 

14 
5 

23 

30 

3D 

30 

31 

22 

31 

31 

14 

16 

19 

15 

29 

20 

20 

21 

14 

19 
7 

17 



HENEY C. LEA— Philadelphia. 



OCT -0 m 



J 



